"Certification Statement for Wp 11, 68, 79, 80, 81, 84, 85, 86, 87, 88, 89, 90, and Wm 16" - Massachusetts

Certification Statement for Wp 11, 68, 79, 80, 81, 84, 85, 86, 87, 88, 89, 90, and Wm 16 is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on March 1, 2017;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
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Download "Certification Statement for Wp 11, 68, 79, 80, 81, 84, 85, 86, 87, 88, 89, 90, and Wm 16" - Massachusetts

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Massachusetts Department of Environmental Protection
Bureau of Water Resources – Groundwater Discharge, Surface
Transmittal Number #
Water Discharge and Reclaimed Water Use Permits
Certification Statement
Facility ID/Permit # (if
known)
For WP 11, 68, 79, 80, 81, 84, 85, 86, 87, 88, 89, 90, and WM 16
A. Engineer Information
Important: When
filling out forms
Engineer Name
on the computer,
use only the tab
Company
key to move your
cursor - do not
use the return
Street Address
City
key.
State
Zip Code
Telephone
Email Address
B. Certification
I,
Name
attest under the pains and penalties of perjury:
(i) that I am a registered professional engineer in the State of Massachusetts, with a concentration in
sanitary, civil, or environmental engineering, and am employed by
Name of Company/Firm
(ii) that
the Engineering Report
for
the Plans and Specifications
Name of Facility
have been prepared in accordance with modern sanitary engineering practice and all applicable
federal, state, and local laws, regulations, and standards, except where otherwise approved by the
Department, including, but not limited to the current editions of TR-16 (Guides For The Design Of
Wastewater Treatment Works), the Massachusetts Guidelines for the Design, Construction,
Operation and Maintenance of Small Wastewater Treatment Facilities with Land Disposal, and the
Massachusetts State Building Code; and
that the facility, as designed, is capable of meeting the required effluent standards described in the
Engineering Report included as part of this permit application.
(iii)
that the Hydrogeological Evaluation prepared for this project and approved by MassDEP on
for
Date
Name of Facility
is consistent with the site conditions and design parameters for this facility, including, but not limited
to: design flow, site design, hydraulic loading rate, and location of public and private potable water
supply wells, and potential impacts of the proposed facility to nearby sensitive receptors and/or
property.
I am aware that there are significant penalties including, but not limited to possible fines and
imprisonment for willfully submitting false, inaccurate, misleading or incomplete information. I am
also aware that submitting false, inaccurate misleading or incomplete information could lead to
modification, suspension or revocation of any permit granted pursuant to this application.
Signature
Massachusetts PE Number
Title
Date
gwdcert.doc • rev. 3/17
Certification WP 11, 68, 79,80,81,84,85,86,87,88,89, 90, & WM 16 • Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Water Resources – Groundwater Discharge, Surface
Transmittal Number #
Water Discharge and Reclaimed Water Use Permits
Certification Statement
Facility ID/Permit # (if
known)
For WP 11, 68, 79, 80, 81, 84, 85, 86, 87, 88, 89, 90, and WM 16
A. Engineer Information
Important: When
filling out forms
Engineer Name
on the computer,
use only the tab
Company
key to move your
cursor - do not
use the return
Street Address
City
key.
State
Zip Code
Telephone
Email Address
B. Certification
I,
Name
attest under the pains and penalties of perjury:
(i) that I am a registered professional engineer in the State of Massachusetts, with a concentration in
sanitary, civil, or environmental engineering, and am employed by
Name of Company/Firm
(ii) that
the Engineering Report
for
the Plans and Specifications
Name of Facility
have been prepared in accordance with modern sanitary engineering practice and all applicable
federal, state, and local laws, regulations, and standards, except where otherwise approved by the
Department, including, but not limited to the current editions of TR-16 (Guides For The Design Of
Wastewater Treatment Works), the Massachusetts Guidelines for the Design, Construction,
Operation and Maintenance of Small Wastewater Treatment Facilities with Land Disposal, and the
Massachusetts State Building Code; and
that the facility, as designed, is capable of meeting the required effluent standards described in the
Engineering Report included as part of this permit application.
(iii)
that the Hydrogeological Evaluation prepared for this project and approved by MassDEP on
for
Date
Name of Facility
is consistent with the site conditions and design parameters for this facility, including, but not limited
to: design flow, site design, hydraulic loading rate, and location of public and private potable water
supply wells, and potential impacts of the proposed facility to nearby sensitive receptors and/or
property.
I am aware that there are significant penalties including, but not limited to possible fines and
imprisonment for willfully submitting false, inaccurate, misleading or incomplete information. I am
also aware that submitting false, inaccurate misleading or incomplete information could lead to
modification, suspension or revocation of any permit granted pursuant to this application.
Signature
Massachusetts PE Number
Title
Date
gwdcert.doc • rev. 3/17
Certification WP 11, 68, 79,80,81,84,85,86,87,88,89, 90, & WM 16 • Page 1 of 1