DDW-2024-008808

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Use Waiver Application for:
Name of Water System:
Name of Drinking Water Source(s)Sn "q*i[e.r Sor,n^r-----J
I,Car,,""{- ll,{ftk n Designated Person (per R309-600) for the
Water S ystem, hereby state that none of the volatile
organic chemicals and/or pesticides within the respective parameter groups have been used in,
disposed of, stored in, transported through, or manufactured within protection zones one, two or
three (or within the management area, if applicable) in the last five years.
Signature:
Date:Y{\att 1rh .'b?A
Note: if applicable, you must provide a list of the chemicals used in, disposed of, stored in, transported through, or
manufactured within protection zones one, two or three where the use of such chemicals within the volatile organic
chemicals and./or pesticide parameter groups is likely.
In general, the presence ofresidences or roads (other than very limited use roads) through zones one, two or three
implies that pesticides and volatile organic chemicals are used, and a use waiver in those cases would not be granted.
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