HomeMy WebLinkAbout2016 Aug 13 - DEP Provisional Use Approval Certification Forms � �:
; Massachusetts Department of Environmental Protection
� Bureau of Resource Protection —Title 5 Program
�
' Provisional Use Approval Certification Forms
Exhibit A: Certification Statement for System Design
impor�a�t: Winston A. Steadman II
When filling out �� Name
forms on the
computer,use attest under the pains and pena�ties of perjury:
only the tab key
to move your Siegmund Environmental Inc �SESI) - Sin�ulair 960-DN
cursor-do not (I) that I am the agent for Company-Technology Name
use the return
key. in the Commonwealth of Massachusetts and am employed by
�:� • All Cape Environmental Inc
Company Name
M � (ii) that based on the information supplied to us by the designer of record of which we relied, the
plans and specifications for the
Singulair 960-DN Concrete for the 56 Jill's Path South Yarmouth
Name of Technology Name of Facility
SESI - Sin�ulair 960-DN Approval
have been prepared in accordance with the Name of Company-Technology
; 11/09/15
design specifications and technology approval dated Date
and
(iii) that the technology, as designed, is capable of ineeting the required effluent standards, provided
the system is properly operated, described in the technology approval dated
. 08/16/2012 rev OS/22/2014
Date
I am aware that there are significant penalties including, but not limited to possible fines and
imprisonment for willfully submitting false, inaccurate, misleading or incomplete information. I am
also aware that submitting false, inaccurate misleading or incomplete information could lead to
modification, suspension or revocation of any technology approval granted to the
SESI- Singulair 960-DN
Name of Company-Technology
Digitally signed by Winston A.Steadman II
Winston A. StEEadCYlall II DN:cn=WinstonA.Steadmanll
Date:2016.09.13 12:47:53-04'00'
Signature
MA4-M
Title
8/13/2016
Date
Form Name•Page 1 of 2
certform•date
w ` L
��'�� Massachusetts Department of Environmental Protection
a Bureau of Resource Protection —Title 5 Program
; ' � Provisional Use Approval Certification Forms
Exhibit B: Certification Statement for System Installation
� Winston A. Steadman II
Name
attest under the pains and penalties of perjury:
(i) that I am the agent for Siegmund Environmental Inc. (SESI) - Singulair 960-DN
Company-Technology Name
in the Commonwealth of Massachusetts and am employed by
� All Ca�e Environmental Inc
Company Name
(ii) that I have inspected the installation for the Sin�ulair 960-500 DN(concrete)
Name of Technology
56 Jill's Path South Yarmouth Mass
for the wastewater disposal system located at Name of Facility
and have found at the time of inspection the installation of the technology to be in accordance with the
Siegmund Environmental Inc.
Company Name
installation specifications and technology approval dated • 8/16/2012 rev 5/22/2014
Date
I am aware that there are significant penalties including, but not limited to possible fines and
imprisonment for willfully submitting false, inaccurate, misleading or incomplete information. I am
also aware that submitting false, inaccurate misleading or incomplete information could lead to
modification, suspension or revocation of any technology approval granted to the
Siegmund Environmental Inc - Singulair 960-DN
Name of Company-Technology
Digitally signed by Winston A.Steadman II
Winston A. SteadC71a11 II DN:cn=WinstonA.Steadmanll
Date:2016.09.13 13:3936-04'00'
Signature
MA WWTPO Grade 4-M
Title
8/13/2016
Date
certform•date Form Name•Page 2 of 2