Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 11
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11APPLICATION FOR CONSTRUCTION PERMIT FOR
Attachment E
PUBLIC WATER SYSTEM - 327 IAC 8-3-3
Chemical Addition
State Form 35058 (R6 / 9-04)
Approved by State Board of Accounts, 2004
Indiana Department of Environmental Management
Drinking Water Branch
A. What is the common / brand name of the intended chemical?
What is the chemical name of the intended chemical?
B. Does the chemical have the approval of any of the following:
Yes
No National Sanitation Foundation (NSF)
Yes
No Underwriters Laboratory (UL)
Yes
No Food and Drug Administration (FDA)
C. What is the purpose of the chemical addition?
D. Technical data supplied on the chemical (check all that apply)
Material Safety Data Sheet
Manufacturer's Label
Other Studies / Literature
Toxicology Data
Case Histories of Chemical Use
E. Describe or provide technical information on the type of proposed feed equipment
F. Describe or provide technical information on the type of proposed feed controls
G. What is maximum and minimum feed range?
H. How have chemical feed rates been determined? (attach supporting documentation)
I. Is there a means of measuring the quantity of chemical used?
Yes
No
J. Do the plans show the following?
Location of all feeders
Yes
No
All points of chemical application
Yes
No
Piping layout
Yes
No
K. What type of cross connection control is provided?
L. Are there leak detectors provided?
Are there spill containments provided?
Yes
No
Yes
No
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