"Dry Cleaner Compliance Certification Form" - Massachusetts

Dry Cleaner Compliance Certification Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on June 1, 2015;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
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Download "Dry Cleaner Compliance Certification Form" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
A. Facility Information
Complete Year
Field Above
1. Physical Location
Important:
When filling out
forms on the
a. Name
computer, use
only the tab key
to move your
b. Street Address 1
cursor - do not
use the return
key.
c. Street Address 2
MA
d. City/Town
e. State
f. Zip Code
g. Phone Number
h. Fax Number
i. Facility Contact – First Name
j. Facility Contact – Last Name
k. Facility Contact – Title
l. Email Address
DEP USE ONLY
*Add up all of the hours worked (during the previous 12
m. Number of Full-Time Employee Equivalents (FTEs)*
months) by the owner, family members, part-time, contract and
Date Received
full-time employees and divide by 2,000. Do not include
You must provide this FTE information.
employees at locations without perc machines, such as store
(MM/DD/YYYY)
fronts. See the Facility Information in the compliance workbook
2. Mailing Address
for an example calculation of FTE.
(For Receiving Certification Reminders)
a. Mailing Address 1
b. Mailing Address 2
c. City/Town
d. State
e. Zip Code
f. Country
3. Owner/Annual Compliance Fee Billing Address
a. Owner Name
b. Owner Mailing Address 1
c. Owner Mailing Address 2
d. City/Town
e. State
f. Zip Code
g. Country
Continue to Next Page ►
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 1 of 12
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
A. Facility Information
Complete Year
Field Above
1. Physical Location
Important:
When filling out
forms on the
a. Name
computer, use
only the tab key
to move your
b. Street Address 1
cursor - do not
use the return
key.
c. Street Address 2
MA
d. City/Town
e. State
f. Zip Code
g. Phone Number
h. Fax Number
i. Facility Contact – First Name
j. Facility Contact – Last Name
k. Facility Contact – Title
l. Email Address
DEP USE ONLY
*Add up all of the hours worked (during the previous 12
m. Number of Full-Time Employee Equivalents (FTEs)*
months) by the owner, family members, part-time, contract and
Date Received
full-time employees and divide by 2,000. Do not include
You must provide this FTE information.
employees at locations without perc machines, such as store
(MM/DD/YYYY)
fronts. See the Facility Information in the compliance workbook
2. Mailing Address
for an example calculation of FTE.
(For Receiving Certification Reminders)
a. Mailing Address 1
b. Mailing Address 2
c. City/Town
d. State
e. Zip Code
f. Country
3. Owner/Annual Compliance Fee Billing Address
a. Owner Name
b. Owner Mailing Address 1
c. Owner Mailing Address 2
d. City/Town
e. State
f. Zip Code
g. Country
Continue to Next Page ►
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 1 of 12
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
A. Facility Information
(continued)
4. Check any of the following conditions that apply to your operation:
a.
This is a Pre-Existing Facility under New
Ownership
New Owner as of Date (MM/DD/YYYY)
b.
This is a New Facility (opened since
September 15 of previous year)
Date Opened (MM/DD/YYYY)
Note: ALL co-
5. Is your business a Co-Residential Facility?
Yes
residential and
(i.e., your business is located in a building with
No
ALL co-located
an apartment or other residential space, even if
perc machines
vacant at the time of this certification.)
must cease
operation on or by
December 21,
2020.
6. Is your business a Co-Located Facility? (i.e.,
Yes
your business is located in a building without a
No
residence, but with one or more of the following:
licensed day care center
health care facility
prison
school (elementary, middle, or high)
children’s pre-school
youth or senior center
B. Change in Status
You are required to indicate below if any of the following apply to your operation. Check any that
apply, then skip to Section D (Comments) and complete the remaining sections of this form.
(If none apply, then continue to Section C).
1.
No dry cleaning operations exist on-site
Dry Cleaning Ceased as of Date (mm/dd/yyyy)
2.
The facility does not use
perchloroethylene (perc) for dry cleaning
Perc Not Used as of Date (mm/dd/yyyy)
a. Hydrocarbon
d. Wet Cleaning
Which of the following dry cleaning methods
b. Siloxane (GreenEarth)
e. Acetal (Solvon, K4)
do you use?
c. Propylene Glycol
f. N-Propyl Bromide (NPB)
(Rynex, Gen-X)
g. Other (Specify)
Specify “Other”
Number of machines using alternate
solvent(s)
Number of Machines Using Alternate Solvent(s)
Estimated number of gallons of alternate
solvent(s) used per year
Gallons
3.
The facility now has only coin-operated
dry cleaning machines
Only Coin-Operated as of Date (mm/dd/yyyy)
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 2 of 12
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
C. Compliance Information
DRY CLEANING MACHINE INFORMATION
1. Please enter the data below for each dry cleaning machine installed at your facility. When a machine
is replaced, enter the date removed; then enter the new replacement machine in a separate column.
Perc Machine
Perc Machine
Perc Machine
a. Manufacturer & Model
a. Manufacturer & Model
a. Manufacturer & Model
b. Serial #
b. Serial #
b. Serial #
c. Installed before 12/9/1991
c. Installed before 12/9/1991
c. Installed before 12/9/1991
d. Installed between 12/9/1991 &
d. Installed between 12/9/1991 &
d. Installed between 12/9/1991 &
1/1/2000
1/1/2000
1/1/2000
Enter all dates as
(MM/DD/YYYY)
e. Install Date if after 1/1/2000
e. Install Date if after 1/1/2000
e. Install Date if after 1/1/2000
f. Date Removed
f. Date Removed
f. Date Removed
g. Control Device(s)*
g. Control Device(s)*
g. Control Device(s)*
*Control devices: refrigerated condenser; carbon adsorber; or both (refrigerated condenser & carbon adsorber)
NOTE: You must provide control device information above and non-perc machine information in Section E.
Answer ALL questions unless you are directed to skip a question. Do not answer questions that you are directed to skip.
Yes - Cease operation and submit a Return to
2. Do you operate a transfer machine?
Compliance Plan
No
3. Did you install a dry-to-dry machine after
Yes
12/21/2005?
No - Skip to question 6
a. Is the machine equipped with a secondary
Yes
carbon adsorber in addition to a
No - submit a Return to Compliance Plan
refrigerated condenser?
Yes – Cease Operation of the perc machine
4. Did you install a perc machine after 7/13/2006
while your business was a Co-Residential
and submit a Return to Compliance plan
Facility? (See Section A, Question 5)
No
Not Applicable - Not Co-Residential
NOTICE: If you installed a perc machine in a Co-Residential building between 12/21/05 and 7/13/06 you are subject to federal
regulations. For more information see the following URL:
http://www.epa.gov/region1/contact/index.html
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 3 of 12
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
C. Compliance Information
(continued)
Yes - Cease Operation of the perc machine and
5. Did you install a perc machine after 11/5/2008
while your business was a Co-Located Facility?
submit a Return to Compliance Plan
(See Section A, Question 6)
No
Not Applicable – Not Co-Located
6. Do you close all dry cleaning machine doors
Yes
immediately after transferring articles and keep
No - Submit a Return to Compliance Plan
the dry cleaning machine doors closed at all
times except during maintenance?
7. Do all of your dry-to-dry machines installed
Yes
before 12/9/1991 have a carbon adsorber or
No - submit a Return to Compliance Plan
refrigerated condenser?
Not Applicable
8. Do all of your dry-to-dry machines installed
Yes
after 12/9/1991 have a refrigerated condenser?
No - Submit a Return to Compliance Plan
Not Applicable
Note: Remember
9. Do you monitor on a weekly basis: ·
Yes
to record the date
No - Submit a Return to Compliance Plan
the refrigeration system high and low
and result in your
pressure during the drying phase, or
weekly record-
the temperature at the end of the cycle on
keeping log. See
Section C9 of the
the outlet side of the refrigerated
Workbook.
condenser?
10. Does the temperature of the refrigerated
Yes
No - Submit a Return to Compliance Plan
condenser outlet fall to 45° F or less (or are
the high and low pressures in the range
specified by the manufacturer’s operating
instructions) at the end of the cool down cycle?
Note: Keep
11. Do you fix all emission control equipment
Yes
records of all
problems within 24 hours or order parts within
No - Submit a Return to Compliance Plan
repairs to the dry
2 days and complete repairs within 5 days?
Not Applicable - No problems have been
cleaning system.
experienced
See Section C11
of the Workbook.
Note: Record the
12. Do you conduct weekly leak checks of your
Yes
dates and results of
dry cleaning system using a leak detection
No - Submit a Return to Compliance Plan
all leak checks in
device in compliance with the standards
your weekly
included in the workbook? (See Section C12 in
Tips: Follow detector manufacturer’s instructions.
recordkeeping log.
See Section C12 &
the Workbook.)
Turn on and/or “zero” the detector in a perc-free
Form C-3
(outdoor) area. Check parts for leaks as solvent is
in the Workbook.
flowing through them.
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 4 of 12
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention
Environmental Results Program
Facility ID #
Dry Cleaner Compliance Certification for 20
C. Compliance Information
(continued)
Note: Finding and
13. If you find leaks, are repairs conducted within
Yes
repairing perc leaks
24 hours or parts ordered within 2 days and
No - Submit a Return to Compliance Plan
in a timely manner
repairs completed within 5 days?
Not Applicable - No leaks found
is an effective way
to reduce perc use
costs and health
effects.
14. Do you maintain all required air quality
Yes
management records for at least 3 years?
No - Submit a Return to Compliance Plan
Required records include:
perc purchase receipts and log
weekly leak checks
weekly emission control monitoring
repair logs and receipts/invoices
manufacturer’s operating manual onsite
(See Section C14 in the Workbook.)
15. Do you operate and maintain your dry cleaning
Yes
system (including the refrigerated condenser
No - Submit a Return to Compliance Plan.
and/or carbon adsorber) in accordance with
the manufacturer’s specifications and
recommendations?
16. How many gallons of perc did you purchase in
the last 12 months? (See Section C16 in the
Gallons
Workbook.)
INDUSTRIAL WASTEWATER REQUIREMENTS
17. Do you place separator water into a device
Yes
which evaporates it to the air? (See Section C17
No
in the Workbook.)
18. Do you use a wet cleaning process or
Yes
standard laundry machine?
No
19. Are you connected to a public sewer?
Yes
No - Skip to question 20
a. If yes, do you discharge industrial
Yes
wastewater (e.g. laundry water or
No - Skip to question 20
separator water) to the public sewer?
b. If yes, do you have permission from the local
Yes
POTW or sewer authority?
No - Contact the local POTW and submit a
Return to Compliance Plan.
dccert • rev. June 2015
ERP Dry Cleaner Certification • Page 5 of 12
Page of 12