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Form Il 532-2648 - Registration Form - Stage Ii Vapor Recovery System - State Of Illinois Page 2

REGISTRATION INSTRUCTIONS

1. LOCAL STATION REGISTRATION: Fill in the business name (e.g., Rob’s Gas On-The-Go), the

business telephone number, the fuel brand name sold (e.g., BP, Marathon, Mobil, Shell), the complete

mailing address (do not enter an intersection as an address), the name of the on-site station manager, and if

applicable, a station email address.

REGIONAL CORPORATE/INDEPENDENT OWNER INFORMATION: Fill in the regional

corporate name of the gas-dispensing facility, the regional corporate telephone number, the name of the

designated corporate contact, their phone number, the complete regional corporate address, and a corporate

email contact address.

3. TYPE OF REGISTRATION: Original Registration: The first time the facility is registering for the

program. Equipment Modification: Any change to the system described in Section 4 VAPOR RECOVERY

SYSTEM. Information Change: Examples of information changes include ownership change, new facility

name, and/or new location of operating records. Stage II Certificate Replacement: Re-registration due to

lost/ missing registration certificate.

4. VAPOR RECOVERY SYSTEM: Fill in the manufacturer’s name and model number that describes the

Stage II system operating at the facility. Identification tags listing the brand name and model number are

usually located at the bottom or top of the dispensers (gas pumps). Enter the date the Stage II system became

operational (e.g. month/year). For each nozzle type used at the facility, enter its manufacturer’s name and

model number and the total number of each type of nozzle. Manufacturer’s name and model number are

typically found on the nozzle handle.

5. VOLUME OF GASOLINE DISPENSED: For existing stations provide the current average monthly

volume (in gallons) of gasoline dispensed at the facility for the last 12 calendar months. For new stations

provide the projected average monthly volume (in gallons) of gasoline to be dispensed at the facility for the

next 12 calendar months.

Average Monthly Volume

75,000 gals

Date 1/06 to 12/06

6. CERTIFICATION: This section certifies the accuracy of information provided in the registration. The

individual completing this form must sign the Stage II registration, then print their name and fill in the date

the form was completed. This form should then be mailed on the address shown on the reverse side.

If you have any questions, please call the Illinois EPA at (217) 557-1441.

STAGE II VAPOR RECOVERY PERMITS

No permit is required from the Office of the State Fire Marshal (OSFM) to install Stage II vapor recovery

systems. However, the contractors doing work on Stage II vapor recovery systems must be registered with

OSFM.

Form Il 532-2648 - Registration Form - Stage Ii Vapor Recovery System - State Of Illinois Page 2