NHDES-W-07-076
Application for products PROPOSED to be applied to land or water
Watershed Management Bureau
RSA 485-A:8
Instructions: Please fill out this form in its entirety, and email it, along with electronic copies of all pertinent documents to . Please mail just the original signed application form (please do not send hard copies of any of the supporting documentation unless requested by NHDES) to:
New Hampshire Department of Environmental Services
29 Hazen Drive
P.O. Box 95
Concord, NH 03302-0095
Attention: Gregg Comstock, P.E.
Watershed Management Bureau
1. Date of Application:
2. Product Trade Name:
3. Vendor Information (i.e., person who is seeking product approval):
Vendor NamePrinted
Signature
Title
Organization
Address
Phone
4. Manufacturer Contact Information:
Manufacturer’s NameContact Person
Title
Address
Phone
Email:
5. General description of the product including its purpose and how its use could benefit the environment.
6. Chemical Composition including the name, CAS # and percent of total for each ingredient/impurity in the product (including polyacrylamides or PAMs). Please note that that the sum of all ingredients / impurities must equal 100%.
Name / CAS # / Percent (%) of TotalPolyacrylamides (PAMs)
Note: The sum must equal 100%.
7. Biodegradability information including how long it takes the product to completely degrade, intermediate and final degradation products (name and CAS #), their solubility in water and if any of the degradation products are toxic to biota.
8. The chemical oxygen demand (COD), biochemical oxygen demand (BOD) (at least 5-day but preferably over 20 days), total nitrogen and total phosphorus concentrations.
9.The pH of the product. If not an aqueous liquid, the pH of water with the product dissolved and in equilibrium with water.
10. Chronic and acute toxicity test reports (the whole report - not just results) of the product conducted in accordance with methods shown in the following table (which is based on Env-Wq 1706.01 for wastewater) that include the LC50, EC50, NOEC, and LOEC for at least two tested species. Unless otherwise allowed by NHDES, test species in fresh waters shall include Daphnid (Ceriodaphnia dubia) and fathead minnow (Pimephales promelas). Test species in marine waters shall include inland silverside (Menidia beryllina) and Mysid Shrimp (Mysidopsis bahia).
Toxicity Test / Allowable USEPA method per 40 CFR 136For acute toxicity in fresh water organisms) and in estuarine and marine organisms / USEPA. October 2002. Methods for Measuring the Acute Toxicity of Effluents and Receiving Waters to Freshwater and Marine Organisms. Fifth Edition. U.S. Environmental Protection Agency, Office of Water, Washington, DC EPA/821/R–02/012.
For chronic toxicity in fresh water organisms / USEPA. October 2002. Short-term Methods for Estimating the Chronic Toxicity of Effluents and Receiving Waters to Freshwater Organisms. Fourth Edition, U.S. Environmental Protection Agency, Office of Water, Washington, DC EPA/821/R–02/013.
For chronic toxicity in estuarine and marine organisms / USEPA. October 2002. Short-term Methods for Estimating the Chronic Toxicity of Effluents and Receiving Waters to Marine and Estuarine Organisms. Third Edition. U.S. Environmental Protection Agency, Office of Water, Washington, DC EPA/821/R–02/014.
11. If the product includes flocculants, proof from the manufacturer that the flocculants are anionic and are certified for compliance with ANSI/NSF Standard 60 drinking water treatment standards.
12. Material safety data sheets (MSDS) for the product including information on potential environmental effects.
13. Information on the potential secondary effects of the product including, but not limited to its potential to impact aquatic plant growth (i.e., due to toxicity or release of nutrients), dissolved oxygen and pH of surface waters.
14. Recommended application procedures of this product including typical dosage rates, and conditions (i.e., weather, season, soils, etc.) when it is best to use this product (i.e., when the product is most efficient and has the lowest potential to adversely impact the environment) and documentation (i.e., studies) supporting the dosage rates and conditions.
15. A description of conditions (i.e., weather, season, soils, etc.) when this product should not be applied (i.e., when it is least efficient and has a greater potential to adversely impact the environment).
16. A description of tests that need to be conducted in advance (i.e., jar tests, etc.) to determine if this product is suitable for a particular application and who should conduct these tests (i.e., the manufacturer, a trained person?).
17. A description of how individuals are trained to properly use this product and if there is a training certification program.
18. A description of how the concentration of the product in surface waters (or in discharges to surface waters) can be reliably determined (note that if the product cannot be reliably measured in surface waters, toxicity tests may be required).
19. A list of state environmental agencies that have approved this product including contact information at each state agency (name, title, phone number and email) and conditions for approval (include documentation from the state environmental agency).
20. A list of state environmental agencies that have reviewed and not approved this product including contact information at each state agency (name, title, phone number and email) and reasons why it was not approved (include documentation from the state environmental agency).
21. Certification from the manufacturer
(must be signed by a person authorized by the manufacturer to sign on behalf of the manufacturer):
I certify under penalty of law that I am authorized to sign on behalf of the manufacturer and that the information provided in this application, including all attachments, for
(insert product trade name)
are, to the best of my knowledge and belief, true, accurate and complete.
Name and DatePrinted
Signature
Date Signed
Title
Organization
Address
Phone
Fax
(603) 271-3297
PO Box 95, Concord, NH 03302-0095
www.des.nh.gov
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