ADEM Form 33 (ADEM-eDWRS-1) "Permittee Registration Form" - Alabama

What Is ADEM Form 33 (ADEM-eDWRS-1)?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEM Form 33 (ADEM-eDWRS-1) by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 33 (ADEM-eDWRS-1) "Permittee Registration Form" - Alabama

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Form ADEM-eDWRS-1
A. Form ADEM-eDWRS-1: Permittee Registration Form
INSTRUCTIONS: A Permittee Responsible Official (WSRO) must complete this form to register a
Permittee for electronic reporting and to request access to the eDWRS for authorized Permittee personnel
to assign them a user role of preparer or certifier. This form should also be used by the Permittee to
authorize Labs and assign them a lab role of preparer or certifier. NOTE: A completed Form ADEM-
eDWRS-2 is required for every user with a role of certifier. A completed Form ADEM-eDWRS-1A is
required from every authorized Lab to request user accounts for Lab personnel. Do Not email the
documents to ADEM. Access for a certifier will not be provided until the documents with original
signatures are received.
Part A: Permittee Information
PWS ID: AL000
Permittee Name:
Street:
Mailing Address:
City:
State:
Zip:
New Application
Manage User Accounts or Lab Associations
Request for Reactivation
Part B: Permittee User Account Information (All fields are required.)
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
ADEM Form 33 5/14
1-A
Form ADEM-eDWRS-1
A. Form ADEM-eDWRS-1: Permittee Registration Form
INSTRUCTIONS: A Permittee Responsible Official (WSRO) must complete this form to register a
Permittee for electronic reporting and to request access to the eDWRS for authorized Permittee personnel
to assign them a user role of preparer or certifier. This form should also be used by the Permittee to
authorize Labs and assign them a lab role of preparer or certifier. NOTE: A completed Form ADEM-
eDWRS-2 is required for every user with a role of certifier. A completed Form ADEM-eDWRS-1A is
required from every authorized Lab to request user accounts for Lab personnel. Do Not email the
documents to ADEM. Access for a certifier will not be provided until the documents with original
signatures are received.
Part A: Permittee Information
PWS ID: AL000
Permittee Name:
Street:
Mailing Address:
City:
State:
Zip:
New Application
Manage User Accounts or Lab Associations
Request for Reactivation
Part B: Permittee User Account Information (All fields are required.)
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
ADEM Form 33 5/14
1-A
AL000
Form ADEM-eDWRS-1
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
Account Action:
User Role:
Add
Update
Remove
Preparer
Certifier
General Information
Last Name:
First Name:
Middle Name/Initial:
Job Title:
Employer’s Name:
Contact Information
E-mail:
Street:
Mailing Address:
City, State, Zip:
Phone Number(s):
ADEM Form 33 5/14
2-A
AL000
Form ADEM-eDWRS-1
Part C: Lab Associations (All fields are required.)
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
Account Action:
Add
Update
Delete Lab Role:
Preparer
Certifier
Lab ID:
Lab Name:
ADEM Form 33 5/14
3-A
AL000
Form ADEM-eDWRS-1
Part D: Permittee Registration
I request that the above identified Permittee be registered for electronic reporting to allow the use of
the ADEM eDWRS. As the Permittee, I agree that all authorized representatives for this Permittee
will follow permit requirements and the procedures for the electronic submission of eDWRS data
and documents, as described in the ADEM eDWRS Participation Package.
Please establish or revise the above user accounts in accordance with the information provided for
each identified Permittee User. The users who are designated to be a Certifier are Authorized
Representatives for this Permittee for all reporting purposes. I understand that all Authorized
Representatives must submit an original completed Form ADEM-eDWRS-2: Terms and Conditions
Agreement.
Please establish or revise the above Permittee’s Lab Authorizations. The Labs that are designated to
be a Certifier are Authorized Lab Representatives for this Permittee for all reporting purposes. I
understand that all Authorized Lab Representatives must submit a Form ADEM-eDWRS-1A: Lab
Registration Form to request Lab User Accounts.
I certify under penalty of law that I have personally examined and am familiar with the information
submitted in this application and all attachments and that, based on my inquiry of those persons
immediately responsible for obtaining the information contained in the application, I believe that the
information is true, accurate and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fine and imprisonment.
Permittee Name (type or print)
Permittee Signature
Date
Official Title (type or print)
For Office Use Only:
Name
Date
Received by:
Approved by:
ADEM Form 33 5/14
4-A
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