MDEQ FORM #2 – USE WAIVER PRELIMINARY INVENTORY

 Public Water System: _____________________________ PWSID No._________________
Address: __________________________________________________________________
City: __________________________________________ County:_____________________
Contact Person: __________________________________ Telephone: __________________
Number of Service Connections _____________________ Population Served: _____________
Storage & Distribution System Materials:___________________________________________
Electrical Utility Company: _____________________________________________________
Submersible Pump Horsepower and /or Brand, Model and Serial # ______________________
_________________________________________________________________________

Map Locator1               Land Use2                                Associated Chemical (s)3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.          Number or letter on map indicating location of this land use.

2.          Surface land use that involves the use of organic chemical (s): crop, distributor, right-of-way, etc.

3.          As determined from visits with the landowner and also using those organic chemicals described in Table 2 and Section III.C. of this document.





MDEQ Form #2

Use Waiver Preliminary Inventory Continued:
Public Water System:___________________________________________________________
Map Locator1               Land Use2                                Associated Chemical (s)3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Compiled By:________________________________  Telephone:___________________
Signature: ___________________________________________________________________
Title: _______________________________________________________________________
Date: _______________________________________________________________________