"Certification for Dioxin and Endothall Testing Assessment for a Source of Supply / Well" - Connecticut

Certification for Dioxin and Endothall Testing Assessment for a Source of Supply / Well is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on September 12, 2006;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
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Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Certification for Dioxin and Endothall Testing Assessment for a Source of Supply / Well" - Connecticut

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CERTIFICATION FOR DIOXIN AND ENDOTHALL TESTING
ASSESSMENT FOR A SOURCE OF SUPPLY / WELL
TO:
Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS# 51 WAT
P.O. Box 340308
Hartford, CT 06134-0308
PWS NAME/PROPOSED SYSTEM NAME:
TOWN:
PWS ID#(if applicable):CT
PROPOSED WELL:
The purpose of this certification is to obtain an assessment to determine if a source of supply/well needs to be
tested for Dioxin and/or Endothall. A Department of Public Health (DPH) review may be used in conjunction
with this assessment to make this determination. If “No” is answered for Dioxin and/or Endothall, the test must
be conducted and documentation as to the potential source of Dioxin and/or Endothall and its respective
location/distance from the source of supply/well needs to be submitted to the DPH.
Dioxin:
1
The watershed or zone of influence
of the source of supply has not been or is not being used for any of the
following land uses: pesticides and herbicides manufacturer, pulp and paper manufacturer, plastics
manufacturer, wood preservative manufacturer, landfill and domestic waste transfer station, or hazardous
waste disposal facility.
Yes
No
Endothall:
Within the past year treatment with endothall has not been applied to any body of water, turf on sod farms or
golf courses within the zone of influence of the source of supply.
Yes
No
1. Zone of influence means the land area within a radius of one (1) mile for unconsolidated aquifer
groundwater sources and a radius of one thousand (1000) feet for confined and bedrock aquifer groundwater
sources.
Statement of Certification
I certify to the best of my knowledge, based on a field assessment and review of available historic land use
records, that responses provided on this form are correct.
______________________________________________________
____________________________
(Print Name) PWS Administrative Official/Certified Operator/Owner
(Title)
______________________________________________________
______________
(Signature)
(Date)
jwc s:\Technical Review Unit\wells\Certification For Endothall and Dioxin Testing Assessment (rev. 091206)
CERTIFICATION FOR DIOXIN AND ENDOTHALL TESTING
ASSESSMENT FOR A SOURCE OF SUPPLY / WELL
TO:
Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS# 51 WAT
P.O. Box 340308
Hartford, CT 06134-0308
PWS NAME/PROPOSED SYSTEM NAME:
TOWN:
PWS ID#(if applicable):CT
PROPOSED WELL:
The purpose of this certification is to obtain an assessment to determine if a source of supply/well needs to be
tested for Dioxin and/or Endothall. A Department of Public Health (DPH) review may be used in conjunction
with this assessment to make this determination. If “No” is answered for Dioxin and/or Endothall, the test must
be conducted and documentation as to the potential source of Dioxin and/or Endothall and its respective
location/distance from the source of supply/well needs to be submitted to the DPH.
Dioxin:
1
The watershed or zone of influence
of the source of supply has not been or is not being used for any of the
following land uses: pesticides and herbicides manufacturer, pulp and paper manufacturer, plastics
manufacturer, wood preservative manufacturer, landfill and domestic waste transfer station, or hazardous
waste disposal facility.
Yes
No
Endothall:
Within the past year treatment with endothall has not been applied to any body of water, turf on sod farms or
golf courses within the zone of influence of the source of supply.
Yes
No
1. Zone of influence means the land area within a radius of one (1) mile for unconsolidated aquifer
groundwater sources and a radius of one thousand (1000) feet for confined and bedrock aquifer groundwater
sources.
Statement of Certification
I certify to the best of my knowledge, based on a field assessment and review of available historic land use
records, that responses provided on this form are correct.
______________________________________________________
____________________________
(Print Name) PWS Administrative Official/Certified Operator/Owner
(Title)
______________________________________________________
______________
(Signature)
(Date)
jwc s:\Technical Review Unit\wells\Certification For Endothall and Dioxin Testing Assessment (rev. 091206)