"Notice of Intent (Noi) to Operate Subject to the 2020 General Permit for Class 1a and 1b Public Transient Non-community Drinking Water Systems" - Vermont

Notice of Intent (Noi) to Operate Subject to the 2020 General Permit for Class 1a and 1b Public Transient Non-community Drinking Water Systems is a legal document that was released by the Vermont Department of Environmental Conservation - a government authority operating within Vermont.

Form Details:

  • Released on November 1, 2019;
  • The latest edition currently provided by the Vermont Department of Environmental Conservation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Vermont Department of Environmental Conservation.

ADVERTISEMENT
ADVERTISEMENT

Download "Notice of Intent (Noi) to Operate Subject to the 2020 General Permit for Class 1a and 1b Public Transient Non-community Drinking Water Systems" - Vermont

Download PDF

Fill PDF online

Rate (4.3 / 5) 21 votes
NOTICE OF INTENT
Drinking Water and Groundwater Protection Division
NOTICE OF INTENT (NOI)
TO OPERATE SUBJECT TO THE 2020 GENERAL PERMIT FOR CLASS 1A AND 1B PUBLIC
TRANSIENT NON-COMMUNITY DRINKING WATER SYSTEMS
This NOI serves as an Officials Contact Form for Transient Non-Community (TNC) water systems that meet the
qualifications of the General Operating Permit. The information provided on this NOI will supersede and
replace the existing information on file. Follow the directions provided to complete each section of the NOI.
A. Water System Information
1. Water System Name:
2. Water System Identification Number (WSID #):
3. 911 Address of Lot(s) where Water System is Located:
4. SPAN of Lot(s) where Water System is Located:
This section identifies the legal name of the Owner of the Water System. The Owner
B. Applicant
is the individual or incorporated entity that is legally and financially responsible for the
Information
Water System. If the Owner is an entity, it must be a valid legal entity in active
standing with the Vermont Secretary of State’s Corporations Division.
1. Water System Owner (Applicant):
2. Applicant’s Mailing Address:
3. Town/City:
4. State:
5. Zip:
6. Applicant Phone:(
)
7. Applicant Email:
C. Co-Applicant
This section identifies the legal name of the Co-Owner of the Water System, if
Information
applicable.
8. Water System Co-Owner (Co-Applicant):
9. Co-Applicant’s Mailing Address:
10. Town/City:
11. State:
12. Zip:
13. Co-Applicant Phone:(
)
14. Co-Applicant Email:
This section identifies the individual authorized by the Owner to receive all
communications regarding the Water System, except financial correspondence. If the
D. Administrative
Administrative Contact is the same as the Owner, write "Same as Owner" on the first
Contact Information
line. Completion of this form does not convey legal authority to the
Administrative Contact to sign this application and act on behalf of the
Owner.
1. Individual’s Name:
2. Individual’s Mailing Address:
3. Town/City:
4. State:
5. Zip:
6. Phone:(
)
7. Email:
This section identifies the individual or entity that is responsible for receiving and
E. Financial Contact
processing invoices and bills sent to the Water System. If the Financial Contact is the
Information
same as the Administrative Contact or Owner, write "Same as Administrative Contact"
or “Same as Owner” on the first line.
1. Individual’s or Firm/Company Name:
November 2019
Page 1 of 2
NOTICE OF INTENT
Drinking Water and Groundwater Protection Division
NOTICE OF INTENT (NOI)
TO OPERATE SUBJECT TO THE 2020 GENERAL PERMIT FOR CLASS 1A AND 1B PUBLIC
TRANSIENT NON-COMMUNITY DRINKING WATER SYSTEMS
This NOI serves as an Officials Contact Form for Transient Non-Community (TNC) water systems that meet the
qualifications of the General Operating Permit. The information provided on this NOI will supersede and
replace the existing information on file. Follow the directions provided to complete each section of the NOI.
A. Water System Information
1. Water System Name:
2. Water System Identification Number (WSID #):
3. 911 Address of Lot(s) where Water System is Located:
4. SPAN of Lot(s) where Water System is Located:
This section identifies the legal name of the Owner of the Water System. The Owner
B. Applicant
is the individual or incorporated entity that is legally and financially responsible for the
Information
Water System. If the Owner is an entity, it must be a valid legal entity in active
standing with the Vermont Secretary of State’s Corporations Division.
1. Water System Owner (Applicant):
2. Applicant’s Mailing Address:
3. Town/City:
4. State:
5. Zip:
6. Applicant Phone:(
)
7. Applicant Email:
C. Co-Applicant
This section identifies the legal name of the Co-Owner of the Water System, if
Information
applicable.
8. Water System Co-Owner (Co-Applicant):
9. Co-Applicant’s Mailing Address:
10. Town/City:
11. State:
12. Zip:
13. Co-Applicant Phone:(
)
14. Co-Applicant Email:
This section identifies the individual authorized by the Owner to receive all
communications regarding the Water System, except financial correspondence. If the
D. Administrative
Administrative Contact is the same as the Owner, write "Same as Owner" on the first
Contact Information
line. Completion of this form does not convey legal authority to the
Administrative Contact to sign this application and act on behalf of the
Owner.
1. Individual’s Name:
2. Individual’s Mailing Address:
3. Town/City:
4. State:
5. Zip:
6. Phone:(
)
7. Email:
This section identifies the individual or entity that is responsible for receiving and
E. Financial Contact
processing invoices and bills sent to the Water System. If the Financial Contact is the
Information
same as the Administrative Contact or Owner, write "Same as Administrative Contact"
or “Same as Owner” on the first line.
1. Individual’s or Firm/Company Name:
November 2019
Page 1 of 2
2. Individual’s or Firm/Company Mailing Address:
3. Town/City:
4. State:
5. Zip:
6. Phone:(
)
7. Email:
This section identifies the Water System’s Designated Operator who will receive copies of
selected correspondence and other communications sent to the Water System, including
outreach in the event of an emergency. The Designated Operator is an individual whom the
F. Designated Operator
Owner has placed in responsible charge of all quality, quantity, process control, and system
Contact Information
integrity decisions involving public health, source, treatment, storage, distribution, and
compliance standards, where applicable. The Designated Operator must hold a valid
certification equal to or greater than the classification of the Water System. Each system must
designate at least one Operator.
1. Operator’s Name:
2. Operator ID:
3. Operator’s Mailing Address:
4. Town/City:
5. State:
6. Zip:
7. Phone:(
)
8. Email:
G. Water System Classification
Select one:
 Class 1A (the water system utilizes no treatment, water softener, or cartridge filters)
 Class 1B (the water system utilizes or has the capability to use chlorine or ultraviolet disinfection)
H. Source Information
The water source(s) serving the water system have received a determination by the Division that they are
not surface water or groundwater under the direct influence of surface water (GWUDI).
Select one:
 Yes
 No
 Do Not Know
If Do Not Know or No, the Division will review available records and, if necessary, schedule a site visit upon receipt of
the NOI to assess compliance with this qualification. In connection with this application, the applicant may be required
to conduct additional water quality sampling when necessary for the Division to issue a determination.
I. Applicant(s) Certification and Signature
I certify that I have an enforceable permanent property interest to access and use the Water System, or I have the
legal authority to sign on behalf of the person or entity that has such property interest. I certify that the statements
and representations made in this application are true and accurate. I consent to allow employees of the State of
Vermont to access the Water System and enter the property on which the Water System is located to conduct
inspections for the purposes of processing this application and ensuring compliance with the General Operating Permit
for Class 1A and 1B Public Transient Non-Community Drinking Water Systems and Water Supply Rule. I agree to
comply with all the terms and conditions of the General Operating Permit for 1A and 1B Public Transient Non-
Community Water Systems, as periodically modified and reissued.
Printed Name of Applicant:
Printed Name of Person with Legal Authority to Sign on Behalf of Applicant (if different):
Applicant Signature:
Date:
Printed Name of Co-Applicant (if applicable):
Printed Name of Person with Legal Authority to Sign on Behalf of Co-Applicant (if different):
Co-Applicant Signature:
Date:
J. Submission of the NOI
Mail the completed and signed form to:
VT DEC - Drinking Water and Groundwater Protection Division
1 National Life Drive, Davis 4
Fax 1-802-828-1541
Montpelier, VT 05620-3521
November 2019
Page 2 of 2
Page of 2