Form DEEP-WPED-MVRF "Minor Variance Request Form" - Connecticut

What Is Form DEEP-WPED-MVRF?

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

Form Details:

  • Released on October 29, 2013;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • 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 DEEP-WPED-MVRF by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEEP-WPED-MVRF "Minor Variance Request Form" - Connecticut

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Minor Variance Request Form
Before completing this form, contact the Water Permitting and Enforcement Division at 860-424-3018, to
verify whether the minor variance in question is eligible for review and approval by DEEP.
Part I: Registrant/Permittee Information
Registrant/Permittee:
Site Address:
City/Town:
State:
Zip Code:
-
Name of Receiving POTW:
Part II: General Permit Information
Type of General Permit:
Permit Number (if applicable):
Part III: Description of Variance
1. List the requirement for which the variance is sought (if applicable, list the subject pollutant and its
effluent limit listed in the subject general permit).
DEEP-WPED-MVRF
1 of 2
Rev. 10/29/13
Minor Variance Request Form
Before completing this form, contact the Water Permitting and Enforcement Division at 860-424-3018, to
verify whether the minor variance in question is eligible for review and approval by DEEP.
Part I: Registrant/Permittee Information
Registrant/Permittee:
Site Address:
City/Town:
State:
Zip Code:
-
Name of Receiving POTW:
Part II: General Permit Information
Type of General Permit:
Permit Number (if applicable):
Part III: Description of Variance
1. List the requirement for which the variance is sought (if applicable, list the subject pollutant and its
effluent limit listed in the subject general permit).
DEEP-WPED-MVRF
1 of 2
Rev. 10/29/13
Part III: Description of Variance (continued)
2. Description of variance:
3. Describe and submit with this form, documentation that the variance sought is negligible and that
granting of the variance will not result in any violation of the subject general permit. (If applicable,
attach lab analyses which describe concentration of the subject pollutants for which the variance is
sought.)
Part IV: Certification
“This document and any attachments were prepared under my direction or supervision in accordance
with a system designed to ensure that qualified personnel properly gather and evaluate the information
submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information contained in this form is, to the best of
my knowledge and belief, true, accurate and complete. I understand that a false statement made in this
information may be punishable as a criminal offense, in accordance with section 22a-6 of the General
Statutes, pursuant to section 53a-157b of the General Statutes, and in accordance with any other
applicable statute.”
Date
Signature of Permittee
Printed Name of Permittee
Title (if applicable)
Note:
Please submit the Minor Variance Request Form to:
WATER PERMITTING AND ENFORCEMENT DIVISION
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
DEEP-WPED-MVRF
2 of 2
Rev. 10/29/13
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