Form DS-EAPW-1 "Waiver Application Form" - New York

What Is Form DS-EAPW-1?

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

Form Details:

  • Released on August 1, 2009;
  • The latest edition provided by the New York State Department of Environmental Conservation;
  • 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 printable version of Form DS-EAPW-1 by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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Download Form DS-EAPW-1 "Waiver Application Form" - New York

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New York State Department of Environmental Conservation
Division of Water
th
Bureau of Flood Protection and Dam Safety, 4
Floor
625 Broadway, Albany, New York 12233-3504
Phone: (518) 402-8185 • FAX: (518) 402-9029
Website:
www.dec.ny.gov
Dam Safety Emergency Action Plan (“EAP”)
Requirement of Services of Professional Engineer (“PE”)
- Waiver Application Form –
6 NYCRR Part 673.7(d) requires that Owners of Class C - High Hazard dams have a
professional engineer (PE) prepare their Emergency Action Plan (EAP). The owner is also
allowed to make a written request of the Director of the Division of Water in the Department’s
Albany office to waive this PE requirement, with respect to some or all of the EAP, based on the
Department’s discretionary consideration of public safety and the site specific characteristics of
the dam and its location. This form serves as the waiver application form.
Dam Name: _________________________________________________________________________
Dam Location: County: ____________________________ Town/City: _________________________
NYS Dam ID No.: _________________
Hazard Class:
“C” (High Hazard)_____________
Location (deg/min/sec): Latitude: ____________________ Longitude: _________________________
Owner Name: _______________________________________________________________________
Owner Address: _____________________________________________________________________
City:
State: __________________ Zip Code: ________________
Owner Telephone: Daytime: _______________________ Evening: ___________________________
Below are listed the typical components of an EAP. The minimum requirements of an EAP are set forth
in the Department’s dam safety regulations (at 6 NYCRR §673) and in the Department’s guidance
documents. Both the regulations and the guidance documents are available on the Department’s website
at
www.dec.state.ny.us.
The dam owner should be fully familiar with these provisions before deciding
whether to complete and submit this Waiver Application Form.
Pursuant to 6 NYCRR §673.7(d), all of the components of the EAP for a Class “C” (high hazard) dam
must be prepared by a PE unless the owner submits this Waiver Application Form and the application is
thereafter approved in writing by the Department.
DS-EAPW-1 (8/09)-DRAFT
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New York State Department of Environmental Conservation
Division of Water
th
Bureau of Flood Protection and Dam Safety, 4
Floor
625 Broadway, Albany, New York 12233-3504
Phone: (518) 402-8185 • FAX: (518) 402-9029
Website:
www.dec.ny.gov
Dam Safety Emergency Action Plan (“EAP”)
Requirement of Services of Professional Engineer (“PE”)
- Waiver Application Form –
6 NYCRR Part 673.7(d) requires that Owners of Class C - High Hazard dams have a
professional engineer (PE) prepare their Emergency Action Plan (EAP). The owner is also
allowed to make a written request of the Director of the Division of Water in the Department’s
Albany office to waive this PE requirement, with respect to some or all of the EAP, based on the
Department’s discretionary consideration of public safety and the site specific characteristics of
the dam and its location. This form serves as the waiver application form.
Dam Name: _________________________________________________________________________
Dam Location: County: ____________________________ Town/City: _________________________
NYS Dam ID No.: _________________
Hazard Class:
“C” (High Hazard)_____________
Location (deg/min/sec): Latitude: ____________________ Longitude: _________________________
Owner Name: _______________________________________________________________________
Owner Address: _____________________________________________________________________
City:
State: __________________ Zip Code: ________________
Owner Telephone: Daytime: _______________________ Evening: ___________________________
Below are listed the typical components of an EAP. The minimum requirements of an EAP are set forth
in the Department’s dam safety regulations (at 6 NYCRR §673) and in the Department’s guidance
documents. Both the regulations and the guidance documents are available on the Department’s website
at
www.dec.state.ny.us.
The dam owner should be fully familiar with these provisions before deciding
whether to complete and submit this Waiver Application Form.
Pursuant to 6 NYCRR §673.7(d), all of the components of the EAP for a Class “C” (high hazard) dam
must be prepared by a PE unless the owner submits this Waiver Application Form and the application is
thereafter approved in writing by the Department.
DS-EAPW-1 (8/09)-DRAFT
-1-
Please identify below with one or more checkmarks the component(s) of the EAP you want to prepare
yourself (without the services of a PE).
Component of EAP
Dam owner requests a waiver of Part 673.7(d) requirement that a
PE prepare the EAP, with respect to the following component(s),
as indicated with checkmark(s)
1.
Notification
□ Waiver requested (Owner to prepare rather than PE)
2.
Statement of Purpose
□ Waiver requested (Owner to prepare rather than PE)
3.
Project Description
□ Waiver requested (Owner to prepare rather than PE)
4.
Emergency Detection,
□ Waiver requested (Owner to prepare rather than PE)
Evaluation and Classification
5.
General Responsibilities
□ Waiver requested (Owner to prepare rather than PE)
Under the EAP
6.
Preparedness
□ Waiver requested (Owner to prepare rather than PE)
7.
Inundation Maps
□ Waiver requested (Owner to prepare rather than PE)
8.
□ Waiver requested (Owner to prepare rather than PE)
(Other)
For each EAP component you have checked above, please use the space below and
Basis for Waiver:
additional page(s), as necessary, to provide your basis that the services of a PE are not necessary for
completion of the EAP in accordance with 6 NYCRR §673 and applicable guidance.
Identify Basis for Waiver
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DS-EAPW-1 (8/09)-DRAFT
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Certification of Owner:
As the owner of the above-designated dam, I certify that I have read or been advised of the statutes,
regulations and guidance governing EAPs and believe that I understand them.
Based on that
understanding, I request approval of the NYSDEC to prepare the above-designated component(s) of the
EAP for the above-designated dam without the services of a PE.
I certify under penalty of law that the answers and information provided in and with this Waiver
Application Form were prepared by me or under my direction or supervision. The answers and
information I submit are, to the best of my knowledge and belief, true, accurate, and complete.
I understand that no waiver is granted by the NYSDEC for the EAP components I have designated above
unless the NYSDEC issues a written Waiver.
This Certification must be signed by an individual on his or her own behalf, or by either a
principal executive officer or ranking elected official, or duly authorized representative of the dam
owner.
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
Company: ____________________________________________________________________________
Signature: ____________________________________________________________________________
Date: ________________________________________________________________________________
Submit Form to:
NYSDEC - Division of Water
Director
th
625 Broadway, 4
Floor
Albany, New York 12233
Phone: (518) 402-8185
Fax: (518) 402-9029
And
NYSDEC - Dam Safety Section
EAP Coordinator
th
625 Broadway, 4
Floor
Albany, New York 12233-3504
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