RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Office Of Water Resources
235 Promenade Street, Providence, RI 02908-5767
Telephone: 401-222-6820, Telecommunication Device for the Deaf: 401-831-5508, FAX: 401-222-6177
WATER QUALITY CERTIFICATION PROGRAM APPLICATION
This form is to be completed for all applications to the Department of Environmental
FOR DEM USE ONLY
Management (DEM), Office of Water Resources, for Water Quality Certification as
Date Received
specified in Rule 13 of the DEM “Water Quality Regulations.” Reference the “Rules
and Regulations Governing the Establishment of Various Fees” for fees listed below.
Attach a non-refundable check payable to “General Treasurer, State of RI.”
PURPOSE OF APPLICATION (Check only one) AND FEES:
Application for Water Quality Certification:
Submit required documentation for Estimated Construction Costs (See Note 1)
Fee:
$200. for estimated construction costs < $250,000.
$400. for estimated construction costs ≥ $250,000.
Request Renewal of Water Quality Certification:
File # ______________
Fee: No fee
Amount Paid:
_____________
Request Modification of Water Quality Certification: File # ______________
Check #:
_____________
Fee: One-half of original fee noted above
File #:
_____________
(A.) PROJECT NAME AND LOCATION:
_____________________________________________________________________________________________________
(Project Name)
(Tax Assessor’s Plat(s) and Lot No.(s))
_____________________________________________________________________________________________________
(Project Location)
(Street Address)
(City/Town)
(ZIP)
(B.) APPLICANT: (Note: Applicant must be the owner of the property on which the activity is proposed.)
_____________________________________________________________________________________________________
(Name)
(Mailing Address)
(City/Town)
(State)
(ZIP)
_____________________________________________________________________________________________________
(Company/Organization)
(Area Code & Telephone Number)
(C.) CONTACT TO ANSWER QUESTIONS REGARDING APPLICATION (If different than Section B):
_____________________________________________________________________________________________________
(Name)
(Mailing Address)
(City/Town)
(State)
(ZIP)
_____________________________________________________________________________________________________
(Company/Organization)
(Title)
(Area Code & Telephone Number)
Water Quality Certification Program Application – Revised May 2005
Page 1 of 2
RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Office Of Water Resources
235 Promenade Street, Providence, RI 02908-5767
Telephone: 401-222-6820, Telecommunication Device for the Deaf: 401-831-5508, FAX: 401-222-6177
WATER QUALITY CERTIFICATION PROGRAM APPLICATION
This form is to be completed for all applications to the Department of Environmental
FOR DEM USE ONLY
Management (DEM), Office of Water Resources, for Water Quality Certification as
Date Received
specified in Rule 13 of the DEM “Water Quality Regulations.” Reference the “Rules
and Regulations Governing the Establishment of Various Fees” for fees listed below.
Attach a non-refundable check payable to “General Treasurer, State of RI.”
PURPOSE OF APPLICATION (Check only one) AND FEES:
Application for Water Quality Certification:
Submit required documentation for Estimated Construction Costs (See Note 1)
Fee:
$200. for estimated construction costs < $250,000.
$400. for estimated construction costs ≥ $250,000.
Request Renewal of Water Quality Certification:
File # ______________
Fee: No fee
Amount Paid:
_____________
Request Modification of Water Quality Certification: File # ______________
Check #:
_____________
Fee: One-half of original fee noted above
File #:
_____________
(A.) PROJECT NAME AND LOCATION:
_____________________________________________________________________________________________________
(Project Name)
(Tax Assessor’s Plat(s) and Lot No.(s))
_____________________________________________________________________________________________________
(Project Location)
(Street Address)
(City/Town)
(ZIP)
(B.) APPLICANT: (Note: Applicant must be the owner of the property on which the activity is proposed.)
_____________________________________________________________________________________________________
(Name)
(Mailing Address)
(City/Town)
(State)
(ZIP)
_____________________________________________________________________________________________________
(Company/Organization)
(Area Code & Telephone Number)
(C.) CONTACT TO ANSWER QUESTIONS REGARDING APPLICATION (If different than Section B):
_____________________________________________________________________________________________________
(Name)
(Mailing Address)
(City/Town)
(State)
(ZIP)
_____________________________________________________________________________________________________
(Company/Organization)
(Title)
(Area Code & Telephone Number)
Water Quality Certification Program Application – Revised May 2005
Page 1 of 2
(D.) PROJECT TYPE/ACTIVITY (Check All That Apply):
Filling of Waters of the State
Marinas – New construction or expansion
Any project ≥ five (5) acres disturbance
Residential Development: six (6) or more dwellings
Commercial, Industrial, State or Municipal Development
Site Disturbances
Flow Alterations
Harbor Management Plan
Other ____________________________________
(E.) GENERAL INFORMATION: Check program and list number(s) of other applications associated with this
project.
Coastal Resources Management Council ____________________________________
US Army Corps of Engineers _____________________________________________
Other ________________________________________________________________
(F.) CERTIFICATION OF APPLICANT:
I hereby certify that I have requested and authorized the investigation, compilation, and submission of all the information, in
whatever form, contained in this Application; that I have personally examined and am familiar with the information submitted
herein; and that such information is true, accurate and complete to the best of my knowledge.
Signature of Applicant: ____________________________________________
Date: ______________________
Print Name: ___________________________________________________
Please return completed form to:
Rhode Island Department of Environmental Management
Office of Water Resources, Water Quality Certification Program
235 Promenade Street, Suite 260
Providence, RI 02908-5767
Office Use Only:
Suitable for Public Notice
Date: _______________
Certification Determination:
Approved
Date: _____________
Denied
Withdrawn
Closed
______________________________ Project Reviewer:
Note 1: Documentation of Estimated Construction Costs (ECC) will be required unless the ECC is > $250,000. ECCs
include all costs of construction activities such as materials, labor, and equipment. ECC shall not include the cost of land
acquisition and consultant fees for planning, design, and construction supervision. The ECC for proposed projects must be
documented and prepared by an appraiser, general contractor, engineer, land surveyor, architect, landscape architect, or
another appropriate qualified professional. Such documentation must be submitted by the applicant with the application.
All ECCs are subject to the review and acceptance by the Department.
Water Quality Certification Program Application – Revised May 2005
Page 2 of 2
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