Note: This form must be completed by the system owner or designated person in responsible charge.

Water System Name: / Water System Number:
Owner: / County:
Address: / City: / State and Zip Code:

To request an asbestos monitoring waiver for your distribution system, complete all of the following:

1.  Complete the Construction Materials Report below - check each box indicating the type of construction materials present in your distribution system, including home plumbing. If any other material is present in the system, check the box next to "Other" and list the material;

2.  Complete all information in the Certification box - be sure to indicate whether or not the source water is in an asbestos vulnerable county (circle appropriate response); and

3.  Submit the completed form to the Asbestos Rule Manager at the address located at the bottom of the page.

IMPORTANT NOTE: Until your request has been approved, your system will be placed on a routine monitoring schedule and will be required to perform asbestos monitoring in your distribution system by December 31, 2016. If your system is located in an asbestos vulnerable county and this waiver request is approved for your distribution system, you must still perform asbestos monitoring at each entry point by the December 31, 2016 deadline. You will be notified in writing as to whether or not a waiver has been approved for your distribution system. Please keep a copy for your records.

Construction Materials Report
□  Lead pipe, piping with lead-lined interior, or lead joint pipe in the distribution mains / □  Copper from piping and alloys, service lines and home plumbing
□  Lead service lines (water main to meter and/or meter to customer’s building) / □  Glass
□  Lead goosenecks/pigtails / □  Coal tar lined pipes and tanks
□  Lead from solder, caulking, alloys and home plumbing / □  Asbestos cement pipe
□  Galvanized piping, service lines, and home plumbing / □  Vinyl lined asbestos cement pipe
□  Brass / □  Cement (non-asbestos)
Ferrous piping materials
□  Steel
□  Cast Iron
□  Ductile Iron / Plastic
□  PVC
□  Polybutylene
□  Polyethylene or Cross-linked polyethylene (PEX)
□  Other:

Certification

County Location of System’s Source Water: ______

Based upon the above Construction Materials Report and the fact that our system’s source(s) water is / is not (please circle one) located in one of the asbestos vulnerable counties (listed on back of this form), I am requesting a distribution system asbestos waiver for the nine-year period of January 1, 2011 through December 31, 2019.

Form Completed by: ______

(Print Name) (Signature)

System Affiliation of Person Completing This Form: ¨ Owner or ¨ Responsible person

Phone Number: ______Email: ______Date Completed: ______

Return this form to: Public Water Supply Section, 1634 Mail Service Center, Raleigh, NC 27699-1634

(Attention: Asbestos Rule Manager)

IMPORTANT NOTE: If your system is located in one of the asbestos vulnerable counties listed below and this waiver request is approved for your distribution system, you must still perform asbestos monitoring at each entry point to the distribution system by the December 31, 2016 deadline.

Asbestos Vulnerable Counties

03 / Alleghany
05 / Ashe
06 / Avery
11 / Buncombe
12 / Burke
13 / Cabarrus
17 / Caswell
18 / Catawba
22 / Clay
29 / Davidson
30 / Davie
34 / Forsyth
39 / Granville
41 / Guilford
42 / Halifax
44 / Haywood
49 / Iredell
50 / Jackson
57 / Macon
58 / Madison
60 / Mecklenburg
61 / Mitchell
80 / Rowan
88 / Transylvania
90 / Union
91 / Vance
92 / Wake (north corridor*)
99 / Yadkin

*The Wake County “north corridor” is bounded by longitudes 78º33’ to 78º49’ and latitudes 35º52’ to 36º05’