| MDEQ FORM #1 – ORGANIC CHEMICAL MONITORING
WAIVER APPLICATION SYSTEM NAME:___________________________________________________________ PWSID #_______________________________________________ TYPE OF ORGANIC CHEMICAL MONITORING WAIVER BEING APPLIED FOR: ______ USE WAIVER ______ SUSCEPTIBILITY WAIVER FOR CONFINED AQUIFER ______ SUSCEPTIBILITY WAIVER FOR UNCONFINED AQUIFER LIST OF SUPPORTING DOCUMENTATION AND FORMS: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ CERTIFICATION OF COMPLETENESS AND ACCURACY: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ SIGNATURE: _______________________________________________________________________ DATE: _____________________________________________________________________________ |