Form DS-AC-1 "Dam Safety Annual Certification Form" - New York

What Is Form DS-AC-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:

  • 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 fillable version of Form DS-AC-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-AC-1 "Dam Safety Annual Certification 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 Annual Certification Form
6 NYCRR Part 673.8 requires that Owners of Class C - High Hazard and Class B -Intermediate Hazard
dams submit an annual certification to the NYSDEC - Dam Safety Section by January 31 of each year.
Please refer to 6 NYCRR Part 673 which governs the definitions and provides additional detail on the
questions listed below.
2019
Reporting Year (prior full calendar year):
Dam Name: _______________________________________________________________________
Dam Location: County: _________________________ Town/City: __________________________
NYS Dam ID: ______________________________________________________________________
 
Hazard Class: (check one)
B-Intermediate
C-High
Location (deg/min/sec): Latitude: _________________ Longitude: ___________________________
Owner Name:_______________________________________________________________________
Owner Address: _____________________________________________________________________
__________________________________________________________________________________
Owner Telephone Number: _____________________ Email:_________________________________
Do you have a written Inspection and Maintenance Plan, in
Yes
No
compliance with Part 673, that is being implemented?
If no, provide a date it will be completed and
____/____/______
implemented:
Do you have a written Emergency Action Plan (EAP) in
Yes
No
compliance with Part 673 and TOGS 3.1.3?
Has an EAP review been completed during the reporting year?
Yes
No
If yes, Date review completed:
___/___/______
Note: The EAP is to be reviewed annually.
Were changes to the EAP needed?
Yes
No
If yes, provide revision date:
___/___/______
If no: certify "I have reviewed the EAP and no changes,
Initial here if no changes were needed: _______
including phone numbers needed" (initial here)
If changes were needed, are the updates attached to
Yes
Sent Separately
this annual certification?
DS-AC-1 (v19.6)
- 1 -
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 Annual Certification Form
6 NYCRR Part 673.8 requires that Owners of Class C - High Hazard and Class B -Intermediate Hazard
dams submit an annual certification to the NYSDEC - Dam Safety Section by January 31 of each year.
Please refer to 6 NYCRR Part 673 which governs the definitions and provides additional detail on the
questions listed below.
2019
Reporting Year (prior full calendar year):
Dam Name: _______________________________________________________________________
Dam Location: County: _________________________ Town/City: __________________________
NYS Dam ID: ______________________________________________________________________
 
Hazard Class: (check one)
B-Intermediate
C-High
Location (deg/min/sec): Latitude: _________________ Longitude: ___________________________
Owner Name:_______________________________________________________________________
Owner Address: _____________________________________________________________________
__________________________________________________________________________________
Owner Telephone Number: _____________________ Email:_________________________________
Do you have a written Inspection and Maintenance Plan, in
Yes
No
compliance with Part 673, that is being implemented?
If no, provide a date it will be completed and
____/____/______
implemented:
Do you have a written Emergency Action Plan (EAP) in
Yes
No
compliance with Part 673 and TOGS 3.1.3?
Has an EAP review been completed during the reporting year?
Yes
No
If yes, Date review completed:
___/___/______
Note: The EAP is to be reviewed annually.
Were changes to the EAP needed?
Yes
No
If yes, provide revision date:
___/___/______
If no: certify "I have reviewed the EAP and no changes,
Initial here if no changes were needed: _______
including phone numbers needed" (initial here)
If changes were needed, are the updates attached to
Yes
Sent Separately
this annual certification?
DS-AC-1 (v19.6)
- 1 -
Certification
I certify under penalty of law that this document and all attachments were prepared under my
direction or supervision and that the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete.
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: _____________________________________________________________________
Address: ______________________________________________________________________
Email: ________________________________________________________________________
Signature: _____________________________________________________________________
Date: _________________________________________________________________________
Send Form and Attachments to:
NYSDEC - Dam Safety Section
th
625 Broadway, 4
Floor
Albany, New York 12233-3504
Phone: (518) 402-8185
Fax: (518) 402-9029
Note: The Dam Owner may have other reporting requirements as identified in Part 673 including, but not limited to,
reporting: i) flow in an erodible auxiliary spillway, ii) change in ownership, and iii) an engineering assessment every 10
years, following the initial engineering assessment.
DS-AC-1 (v19.6)
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