Arizona Administrative Code › Title 18 - ENVIRONMENTAL QUALITY › Chapter 4 - DEPARTMENT OF ENVIRONMENTAL QUALITY - SAFE DRINKING WATER › Article 6 - CAPACITY DEVELOPMENT REQUIREMENTS FOR A NEW PUBLIC DRINKING WATER SYSTEM › Appendix B - Drinking Water Capacity Development Statement of Responsibility

Current through Register Vol. 30, No. 28, July 12, 2024
Applicant Information: Name:
						  Mailing Address Phone Number: Fax Number: E-mail:
Statement Information: 1) Name
						  of Water System:__________________________________________PWS ID#_____________
						  2) Ownership Type (Please check all that apply): ____Sole Proprietor ____Major
						  Stockholders ____Board of Directors ____Cooperative ____Government Agency
						  ____District ____Public Entity ____Corporation ____Limited Liability
						  Corporation ____Other (please explain)
						  _________________________________________________________________ 3) Name of
						  Owner(s): (Check one) See below Attach a separate sheet if more space is needed
						  Owner 1: Owner 2: Owner 3: 4) Agencies with rules applicable to the Water
						  System: (Please check all that apply) ____Arizona Department of Environmental
						  Quality ____Arizona Corporation Commission ____Arizona Department of Water
						  Resources ____Arizona Department of Real Estate ____Arizona Department of
						  Commerce ____Arizona Department of Agriculture ____Arizona Department of
						  Corrections ____Office of the Fire Marshal ____Arizona Land Department
						  ____Arizona Department of Revenue ____Arizona Department of Transportation
						  ____Maricopa County Environmental Services ____Pima County Department of
						  Environmental Quality ____Environmental Protection Agency Region IX
						  ____Other(s) please
						  specify___________________________________________________________________ page
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5) Statement of Intent (Select
						  one): ____It IS the intent of the owner or developer of this NEW CWS or NEW
						  NTNCWS to transfer ownership of the water system. As part of the ownership
						  transfer, it is understood that the owner or developer has a responsibility to
						  disclose and transfer ALL information relevant to the construction and
						  operation of the water system to the new owner. ____It is NOT the intent of the
						  owner to transfer ownership of the NEW CWS or NTNCWS within one year of the
						  completion of construction of the water system. 6) Date owner expects to begin
						  operation: Month_________________ Day _____________ Year______________________
						  7) Drinking Water Sources used: (Select all that apply) ____Ground Water
						  ____Purchased Ground Water ____Surface Water ____Purchased Surface Water 8)
						  Table of Contents of Systems Elementary Business Plan (Please check one):
						  ____The Table of Contents of the Elementary Business Plan is attached. ____The
						  Table of Contents of the Elementary Business Plan is summarized below.
						  Summary______________________________________________________________ 9)
						  Signature of each current owner: Check if additional signature page is
						  attached.____ I agree to comply with the requirements of 18 A.A.C. 4, Article
						  6. Print
						  Name:____________________________Signature:__________________________Date:___________
						  Print
						  Name:____________________________Signature:__________________________Date:___________
						  Print
						  Name:____________________________Signature:__________________________Date:___________
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