3930-FM-BSDW0020f
Module 5
Rev. 8/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
PWSID #
MONITORING WAIVER APPLICATION
MODULE 5 – ASBESTOS, DIOXIN AND PCBs WAIVER REQUEST
A.
General:
Entry Point (EP) ID #:
(Please complete a separate form for each EP)
A waiver is being requested for the following:
Asbestos (9-year waiver)
Dioxin (3-year waiver)
PCBs (3-year waiver)
B.
Waiver Criteria:
(Please complete all applicable sections)
1. Asbestos:
a. Does the distribution system contain asbestos-cement pipe?
YES
NO
b. Has optimized corrosion control treatment been implemented and maintained?
YES
NO
N/A
c. Are the PWS sources vulnerable to asbestos contamination, including contamination from
asbestos-bearing rock formations?
YES
NO
N/A
2. Dioxin:
Are there any potential sources of dioxin located within 1,000 feet of a groundwater source or within
1 mile upstream of a surface water source?
YES
NO
3. PCBs:
Are there any potential sources of PCBs located within 1,000 feet of a groundwater source or within
1 mile upstream of a surface water source?
YES
NO
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3930-FM-BSDW0020f
Module 5
C.
Rev. 8/2015
PWSID #
Source Water Protection Information:
Please complete Module 7 (Site Map and Land Use Inventory) for each source and identify all land uses,
including potential sources of Asbestos, Dioxin or PCBs.
Please describe the steps taken to determine the potential sources of contamination:
D.
Certification:
The information contained herein is true and correct to the best of my knowledge, information and belief.
The information given is subject to the penalty provisions of the Crimes Code regarding unsworn falsification
to authorities (49 P.S. §4904).
Signature
Date
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