"Engineer's Certificate of Completion for a Wastewater Treatment Plant Constructed in Conformance With an Individual Aquifer Protection Permit" - Arizona

Engineer's Certificate of Completion for a Wastewater Treatment Plant Constructed in Conformance With an Individual Aquifer Protection Permit is a legal document that was released by the Arizona Department of Environmental Quality - a government authority operating within Arizona.

Form Details:

  • Released on August 1, 2020;
  • The latest edition currently provided by the Arizona Department of Environmental Quality;
  • Ready to use and print;
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  • 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 Arizona Department of Environmental Quality.

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ENGINEER’S CERTIFICATE OF
COMPLETION
F
W
T
P
C
OR A
ASTEWATER
REATMENT
LANT
ONSTRUCTED IN
C
I
A
P
P
ONFORMANCE WITH AN
NDIVIDUAL
QUIFER
ROTECTION
ERMIT
A
C
PPLICANT
ERTIFICATION
1
Project Name and Number
Project Name
APP File No.
LTF No.
County
City
2
Applicant
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
3
Contact Person/Agent (if different from applicant)
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
4
Project Description
5
Operation and Maintenance (O&M) Information
A) Principal/Supervisory Operator Information
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
AZ Operator WW Treatment ID No.
Expiration Date
B) The O&M manual addresses the components documented in the attached Engineers Certificate of Completion, and is
available for inspection upon request by the Department
Yes
No
6
Certification (To be completed by the applicant in item 2 above)
I, _______________________________________, certify that this Engineer Certificate of Completion and all attachments
were prepared under my direction or authorization and all information is, to the best of my knowledge, true, accurate and
complete. I also certify that the wastewater treatment facility described in this form is constructed, designed, and operated in
accordance with terms and conditions of Arizona Revised Statutes (A.R.S.) Title 49, Chapter 2, Articles 1, 2 and 3; Arizona
Administrative Code (A.A.C.) Title 18, Chapter 9, Articles 1 and 2; A.A.C. Title 18, Chapter 11, Article 4; and conditions set
forth regarding individual aquifer protection permits. All activities are in conformance with all plans, specifications, manuals
and other documents submitted to ADEQ for the development of this specific project permits. I am aware that there are
significant penalties for submitting false information including permit revocation as well as the possibility of fine and
imprisonment for knowing violations.
Signature
Date
R
AUGUST 2020
P
1
2
EVISED
AGE
OF
1110 W
W
, P
, AZ 85007
EST
ASHINGTON
HOENIX
.
.
WWW
AZDEQ
GOV
ENGINEER’S CERTIFICATE OF
COMPLETION
F
W
T
P
C
OR A
ASTEWATER
REATMENT
LANT
ONSTRUCTED IN
C
I
A
P
P
ONFORMANCE WITH AN
NDIVIDUAL
QUIFER
ROTECTION
ERMIT
A
C
PPLICANT
ERTIFICATION
1
Project Name and Number
Project Name
APP File No.
LTF No.
County
City
2
Applicant
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
3
Contact Person/Agent (if different from applicant)
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
4
Project Description
5
Operation and Maintenance (O&M) Information
A) Principal/Supervisory Operator Information
Name
Phone
Title
Email
Firm Name
Mailing Address
City
State
Zip
AZ Operator WW Treatment ID No.
Expiration Date
B) The O&M manual addresses the components documented in the attached Engineers Certificate of Completion, and is
available for inspection upon request by the Department
Yes
No
6
Certification (To be completed by the applicant in item 2 above)
I, _______________________________________, certify that this Engineer Certificate of Completion and all attachments
were prepared under my direction or authorization and all information is, to the best of my knowledge, true, accurate and
complete. I also certify that the wastewater treatment facility described in this form is constructed, designed, and operated in
accordance with terms and conditions of Arizona Revised Statutes (A.R.S.) Title 49, Chapter 2, Articles 1, 2 and 3; Arizona
Administrative Code (A.A.C.) Title 18, Chapter 9, Articles 1 and 2; A.A.C. Title 18, Chapter 11, Article 4; and conditions set
forth regarding individual aquifer protection permits. All activities are in conformance with all plans, specifications, manuals
and other documents submitted to ADEQ for the development of this specific project permits. I am aware that there are
significant penalties for submitting false information including permit revocation as well as the possibility of fine and
imprisonment for knowing violations.
Signature
Date
R
AUGUST 2020
P
1
2
EVISED
AGE
OF
1110 W
W
, P
, AZ 85007
EST
ASHINGTON
HOENIX
.
.
WWW
AZDEQ
GOV
E
C
C
I
A
P
P
NGINEERS
ERTIFICATE OF
OMPLETION FOR AN
NDIVIDUAL
QUIFER
ROTECTION
ERMIT
Engineer’s Certificate of Completion
7
Construction Work Performed (Items 7-12 to be completed by Engineer)
The work on this project was completed on
(date) by the following:
Contractor Name
Work Performed
License Type
Expected discharge date:________________________ (cannot discharge under a permit prior to submitting this completed
certificate to the Department pursuant to A.A.C. R18-9-B203.E)
List of additional contractors attached
8
Leakage and Performance Test Results
Pre-operational leakage tests (yard pipes, basins, manholes, lift stations, and/ or force mains) and performance tests (blowers,
pumps, valves, distribution pipes, backflow prevention valves and disinfection) were conducted and/or observed by the
following persons, with the results satisfactorily meeting all pertinent requirements in Arizona Administrative Code (A.A.C.)
Title 18, Chapter 9, Articles 1 and 2. All field test result reports attached to this certificate have been reviewed and approved by
the signing engineer.
Contractor/Agency/Tester Name
License Type
Test Performed/Observed by
Satisfactory Results
Yes
Yes
Yes
List of additional contractors is attached
9
Construction Plans and Specifications
The construction plans and specifications submitted for the development of the Individual Aquifer Protection Permit
specific to this facility accurately reflect final location, configuration, and construction of components. Final plan sets shall be
submitted as as-built plans reflecting appropriate and proper engineering design practices with all seals by registered
professionals.
Are process modifications, capacity expansions or discharge characteristic modifications expected to be filed with ADEQ for
this facility? Within the next:
One year
Two years
Three years
If yes, please provide a description on a separate page.
10
Other Permits
An AZPDES Permit is required for discharge. Permit No.
A Floodplain Use Permit is required. List permitting authority.
List other environmental permits (include odor/noise nuisance waivers and allowances)
11
Additional Information Attached
No
Yes (please describe on a separate page)
12
Certification Statement
I, ____________________________________________ (print name), a
Professional Engineer registered in the State of Arizona, have provided the
Affix Seal per A.A.C. R4-30-304(E)
evidence listed in items 5-11 that the construction of the above described project
was completed, to the best of my knowledge.
R
A
2020
P
2
2
EVISED
UGUST
AGE
OF
1110 W
W
, P
, AZ 85007
EST
ASHINGTON
HOENIX
.
.
WWW
AZDEQ
GOV
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