Form 21j - Appendix 1r - Renewal Application For Certificate Of Compliance For Dispensing Facilities

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Appendix 1R
Renewal Application for Certificate of Compliance for Dispensing Facilities
THE COMMONWEALTH OF MASSACHUSETTS
Department of Revenue
Underground Storage Tank Board
th
100 Cambridge Street, 7
Floor – P.O. Box 9563
Boston, MA 02114
RENEWAL APPLICATION FOR CERTIFICATE OF COMPLIANCE FOR DISPENSING FACILITIES
I. INSTRUCTIONS
Please type or print in ink and sign the owner/operator certification on the reverse side. A copy of the current Facility Detail Report
from MassDEP’s online UST Data Management System (DMS) must accompany this application. Please note that the facility
owner identified in Section II below must match the information in the MassDEP UST DMS. Also enclose a copy of:
(1) If a Marina, a Marine Fueling Permit (FP-294)
(2) Applicable current testing reports (cathodic protection, product line, line leak detector, etc.). See below.
Note: The UST Program encourages you to use our internet based “eUST” application to submit and manage your Certificate of
Compliance (COC) Renewal Application in lieu of this form. Please visit our website for more information:
,gov/ust
II. OWNERSHIP OF TANK(S)
III. LOCATION OF TANK(S)
__________________________________________________
_________________________________________________________
Owner Name (Corporation, Individual, or Other Entity)
Facility Name (Corporation, Individual, or Other Entity)
__________________________________________________
_________________________________________________________
Street Address
Street Address (P.O. Box not acceptable)
__________________________________________________
_________________________________________________________
City
State
Zip
City
State
Zip
__________________________________________________
_________________________________________________________
Mail Address if Different from Street Address
County
__________________________________________________
_________________________________________________________
Phone Number (Include Area Code)
Phone Number (include Area Code)
– UST Facility Identification / COC Number: _____________
IV. GENERAL
Facility Detail Report attached?
Marine Fueling Permit attached?
Not Applicable
.
V
UST COMPLIANCE TESTING
Cathodic Protection System Testing: Check applicable box
Not Applicable - UST system is Fiberglass, Composite, etc.
Sacrificial Anode System (If selected, please check the applicable testing frequency below)
Annual test report (-0.85 V to -0.90 V) or
3-yr test (> -0.90 V) Attach report.
Impressed Current System - Attach annual test survey report
.
Product Piping Test Report: Check applicable box
Pressurized - Attach annual line and line leak detector test report.
Pressurized equipped with interstitial monitoring - Attach annual line leak detector test report.
Suction, check valve at tank - Attach 3-year test report (No test required if equipped with interstitial monitor)
Suction, check valve at dispenser only, none at tank– No test required.
Note: Failure to provide applicable test reports may result in disapproval of this COC renewal application and the possible
revocation of the current existing COC for Failure to Properly Renew.
Continued on Reverse Side
Form 21J- Appendix 1R (Rev. 9/10/15)
Page 1 of 2.

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