Hawaii Administrative Rules › Title 11 - DEPARTMENT OF HEALTH › Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS › Chapter 62 - WASTEWATER SYSTEMS › Form A - CERTIFICATION FORM - LAND APPLICATION

Current through June, 2024
July 1, 2014
Instructions:
1. Each form must be signed and dated to be valid.
2. The certifier shall print or type his name below the
				  signature line and print or type the certifier's title, if any, where
				  indicated.
3. When the certifier checks a box or fills in a line other
				  than the signature or date lines, the certifier shall initial below the check
				  or the line, unless the certifier uses preprinted versions of the form which
				  delete the boxes and lines which must be initialed.
[ ] For preparers only, I certify, under penalty of law,
				  that:
[ ] 1. The pollutant concentration ceiling limits in Table IV
				  of chapter
				  11-62, HAR have been met.
[ ] 2. The following pathogen requirements have been
				  met:
[ ] a. The Class A pathogen requirements of §
									11-62-46(a), HAR,
				  specifically §
									11-62-46(3)
				  (_____); or
[ ] b. The Class B pathogen requirements of
				  40 CFR
				  §503.32(b),
				  specifically §503.32 (b) (______) and notification each land owner and
				  land applier of wastewater sludge which I have prepared, of the spacing and
				  site restrictions in §
									11-62-43(g), HAR;
				  and the management requirements in §
									11-62-43(h),
				  HAR.
[ ] 3. Vector attraction reduction:
[ ] a. One of the vector attraction reduction requirements in
				  40 CFR §
										503.33(b) (1) through (8),
				  has been met, specifically §503.33(b) (___); or
[ ] b. I have not met the one of the requirements of
				  40 CFR §
										503.33(b) (1) through (b)
				  (8), and I informed the land applier and the owner of the land application site
				  that one of the vector attraction reduction requirements in
				  40 CFR §
										503.33(b) (9) or (b) (10)
				  must be met;
[ ] For appliers of wastewater sludge only, I certify, under
				  penalty of law, that:
[ ] 4. One of the vector attraction reduction requirements in
				  40 CFR §
										503.33(b) (9) or (b) (10)
				  has been met, specifically §503.33(b) (____);
[ ] 5. The spacing and site restrictions in §
									11-62-43(g)  have
				  been met; and
[ ] 6. The management requirements in §
									11-62-43(h), HAR
				  have been met.
[ ] For appliers of septage only, I certify, under penalty of
				  law, that:
[ ] 7. One of the pathogen requirements in
				  40 CFR
				  §
										503.32(c) (1) or (c)
				  (2) has been met, specifically §503.32(c) (____);
[ ] 8, One of the vector attraction reduction requirements in
				  40 CFR §
										503.33(b) (9), (b) (10), or
				  (b) (12) has been met, specifically §503.33(b) (____);
[ ] 9. The spacing and site restrictions in §
									11-62-44(g), HAR
				  have been met; and
[ ] 10, The management requirements in §
									11-62-44(h), HAR
				  have been met.
I certify, under penalty of law, that the information that
				  will be used to determine compliance with the foregoing requirements was
				  prepared under my direction and supervision in accordance with the system
				  designed to ensure that qualified personnel properly gather and evaluate this
				  information. I am aware that there are significant penalties for false
				  certification including the possibility of fine and imprisonment.
Date_________________________
				  Name_______________________
Title:______________________