Form YG5452 "Application for a Permit to Operate a Trucked Drinking Water Distribution System" - Yukon, Canada

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Download Form YG5452 "Application for a Permit to Operate a Trucked Drinking Water Distribution System" - Yukon, Canada

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APPLICATION FOR A PERMIT TO OPERATE A
TRUCKED DRINKING WATER DISTRIBUTION SYSTEM
The provision of this information will help to determine if your trucked drinking water distribution system supplies safe
water and meets the requirements of the Drinking Water Regulation, under the Public Health & Safety Act.
SECTION 1: OWNER/PROPONENT INFORMATION
Legal Name of Owner
Contact Person
(Municipality, First Nation, Yukon Government, Business, other)
Mailing Address
City/Town/Village
Province/Territory
Postal Code
Telephone
Fax
Email
SECTION 2: WATER DELIVERY TRUCK STORAGE FACILITY
Name of Water Delivery Service
Legal Description for Truck Storage Facility
Lot
Quad
Plan
Municipal Address and GPS Location of Truck Storage Facility
(Street Name, Easting and Northing)
Estimated Number of Persons Served
Average Weekly Volume of Water Delivered
(Litres)
Number of Delivery Sites: Total _________
Residences __________
Businesses __________
Other ______________
Name of Operator
Telephone
Name of Back-up Operator
Telephone
SECTION 3: SOURCE WATER SOURCE
Where do you get your drinking water?
(i.e., name of Permitted Large Public Drinking Water System)
YG(5452EQ)F2 Rev.07/2017
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APPLICATION FOR A PERMIT TO OPERATE A
TRUCKED DRINKING WATER DISTRIBUTION SYSTEM
The provision of this information will help to determine if your trucked drinking water distribution system supplies safe
water and meets the requirements of the Drinking Water Regulation, under the Public Health & Safety Act.
SECTION 1: OWNER/PROPONENT INFORMATION
Legal Name of Owner
Contact Person
(Municipality, First Nation, Yukon Government, Business, other)
Mailing Address
City/Town/Village
Province/Territory
Postal Code
Telephone
Fax
Email
SECTION 2: WATER DELIVERY TRUCK STORAGE FACILITY
Name of Water Delivery Service
Legal Description for Truck Storage Facility
Lot
Quad
Plan
Municipal Address and GPS Location of Truck Storage Facility
(Street Name, Easting and Northing)
Estimated Number of Persons Served
Average Weekly Volume of Water Delivered
(Litres)
Number of Delivery Sites: Total _________
Residences __________
Businesses __________
Other ______________
Name of Operator
Telephone
Name of Back-up Operator
Telephone
SECTION 3: SOURCE WATER SOURCE
Where do you get your drinking water?
(i.e., name of Permitted Large Public Drinking Water System)
YG(5452EQ)F2 Rev.07/2017
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Print
Clear
SECTION 4: ADDITIONAL INFORMATION
The following information must be submitted as part of your application. Please ensure you have attached a separate
document(s) for each of the items below.
Trucked Distribution System (for each truck)
• type of truck (eg. Freightliner)
• capacity of truck tank
• material of construction for water tank
• description of access port(s) and vents
• material of construction of water
• description of hose compartment
hose and nozzle
• location and type of backflow preventor
• delivery schedule (provide a copy)
• description of cleaning and disinfection
• other duties of water truck driver(s)
• location of equipment manuals
procedures, including frequencies
and written procedures (provide
• frequency of equipment manual and
• plans for provision of equipment and
copies of procedures)
procedure updates
supplies during emergencies
• provision for water truck storage
• pictures of each truck, showing label-
• free available chlorine records for
(see Section 82(1) of the Drinking
ing (signs), hose compartment (open
previous 3 months
Water Regulation)
and closed), access port(s), vent(s),
hose and nozzle, and any other
• pictures of truckfill station
• other relevant information,
important features
documents, and/or pictures
Operator Certification
• names of operators
• Environmental Operator’s
• dates of certifcation
Certification Program class of
• current status of certificate for
• other relevant information,
certification for each operator
each operator
documents, and/or pictures
Bacteriological Sampling Program
• frequency of sampling (see Schedule
• location and description of all
• other relevant information,
C of the Drinking Water Regulation)
sampling points
documents, and/or pictures
SECTION 5: CERTIFICATION
I certify that the information contained in this form and the attached information is complete and accurate to the best
of my knowledge.
Y Y Y Y
/
M M
/
D D
Signature of Owner __________________________________________________________
Date ___________________
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