Form 21j - Appendix 1r - Renewal Application For Certificate Of Compliance For Dispensing Facilities Page 2
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1
2Appendix 1R, continued
VI. CERTIFICATION
Owner/Operator Certification
I certify to the best of my knowledge and belief that this Dispensing Facility and UST System is in Full Compliance with the provisions of
310 CMR 80.00, 503 CMR 2.00 and M.G.L. Chapter 21J. I hereby consent to all audits of any payments, submissions to the Board, and
inspections made pursuant to law and incidental to the issuance of licenses, registrations, permits, certificates and the operation of this
UST System. I further certify that I am authorized to execute this form. I declare under the penalty of perjury that to the best of my
knowledge and belief the statements made and information given herein are true as of the date of this application. I am aware that there
are significant penalties for submitting false information, including possible fines, civil penalties and imprisonment.
Check One:
Owner
Owner/Operator Signature: ____________________________________
Date: ________________
Operator
Professional Engineer Certification – Substantial Modification of UST System
I certify that all UST System testing, leak detection, corrosion protection, spill containment and overfill prevention meets the requirements
of 310 CMR 80.00 for this type of UST System as documented on the Facility Detail Report. I declare under the penalty of perjury that to
the best of my knowledge and belief the statements made and information given in the above certification are true.
Professional Engineer Certification is required if a substantial modification (e.g. install/remove tank and/or piping) has occurred
since the issuance of the current COC. (For details, refer to 503 CMR 2.07(2)(d)(2)).
Signature:
Date:
_________________________________________
________________________
_____________________________________________________________________________________
Name, Address, and Mass. P.E. Reg. #
P.E. Stamp (required)
THIS SECTION FOR
DOR OFFICE USE ONLY
Reviewer initials: __________
Date Stamp
Was owner/operator contacted for clarification?
Yes
No
Findings: _______________________________________________________________________________
_______________________________________________________________________________________
Facility Detail Report current?
Yes
No
Testing/TPI reviewed?
Yes
No
Annual tank fees billed & current?
Yes
No
APPROVED
DISAPPROVED/REVOKED FOR FAILURE TO PROPERLY
RENEW
Name
Reason for Disapproval
________________________________
:________________________________
Title
________________________________
____________________________________________________________
Form 21J-Appendix 1R (Rev. 9/10/15) Page 2 of 2
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