Form B "Waiver Application or Renewal - Vulnerablility Asset Program" - Nevada

What Is Form B?

This is a legal form that was released by the Nevada Department of Conservation and Natural Resources - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2022;
  • The latest edition provided by the Nevada Department of Conservation and Natural Resources;
  • 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 B by clicking the link below or browse more documents and templates provided by the Nevada Department of Conservation and Natural Resources.

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Download Form B "Waiver Application or Renewal - Vulnerablility Asset Program" - Nevada

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B U R E A U O F S AF E D R I N K I N G WA T E R
W A I V E R A P P L I C A T I O N O R R E N E W A L
F O R M “ B ”
P W S N A M E
P W S I D #
P W S S O U R C E I D *
* C o m p l e t e a f o r m f o r e a c h s o u r c e
I O C I I
I O C V
C Y A N I D E
S O C I I & V
D I O X I N
A S B E S T O S
Have there been any major changes to your water distribution system?
YES
(If yes, please elaborate in the space provided below.)
NO
Has there been any new construction, development, or zoning changes within a 3000-
YES
foot radius of your well in the past 3 years? (If yes, please elaborate in the space
NO
provided below.)
Have there been any activities or occurrences (chemical spills, floods, improper storage
of chemicals, etc.) in the past 3 years that may have potentially increased the possibility
YES
of contamination to the aquifer supplying your source water within a 3000-foot radius?
NO
(If yes, please elaborate in the space provided below.)
For any questions contact Rheanna Morgan at: (775) 687–9448 or rmorgan@ndep.nv.gov
I hereby affirm the above information I have provided is true and accurate to the best of my knowledge.
Print Name
Title
Signature
Date
901 S. Stewart Street, Suite 4001 • Carson City, Nevada 89701 • p: 775.687.4670 • f: 775.687.5856 • ndep.nv.gov
Printed on recycled paper
Revised: March 2022
B U R E A U O F S AF E D R I N K I N G WA T E R
W A I V E R A P P L I C A T I O N O R R E N E W A L
F O R M “ B ”
P W S N A M E
P W S I D #
P W S S O U R C E I D *
* C o m p l e t e a f o r m f o r e a c h s o u r c e
I O C I I
I O C V
C Y A N I D E
S O C I I & V
D I O X I N
A S B E S T O S
Have there been any major changes to your water distribution system?
YES
(If yes, please elaborate in the space provided below.)
NO
Has there been any new construction, development, or zoning changes within a 3000-
YES
foot radius of your well in the past 3 years? (If yes, please elaborate in the space
NO
provided below.)
Have there been any activities or occurrences (chemical spills, floods, improper storage
of chemicals, etc.) in the past 3 years that may have potentially increased the possibility
YES
of contamination to the aquifer supplying your source water within a 3000-foot radius?
NO
(If yes, please elaborate in the space provided below.)
For any questions contact Rheanna Morgan at: (775) 687–9448 or rmorgan@ndep.nv.gov
I hereby affirm the above information I have provided is true and accurate to the best of my knowledge.
Print Name
Title
Signature
Date
901 S. Stewart Street, Suite 4001 • Carson City, Nevada 89701 • p: 775.687.4670 • f: 775.687.5856 • ndep.nv.gov
Printed on recycled paper
Revised: March 2022