| (AI-1) |
Applicant name, mailing address, street address,
city/town, state, zip code, telephone and fax, with
area code, time zone. The applicant must be vested
with the authority to represent the manufacturer in
this capacity.
|
| (AI-2) |
Contact individual (if different from person in Item
1) name, mailing address, street address, city/town,
state, zip code, telephone and fax, with area code,
time zone.
|
| (AI-3) |
Manufacturing facility location/address, mailing
address, street address, city/town, state, zip code.
|
| (AI-4) |
Name of on-site sewage disposal system additive
product. (One product per application. If
identical formulations of product are marketed under
different product names or distributor labels, list
them here. If product formulations vary, submit
separate applications for each product.)
|
| (AI-5) |
List of firms, companies, or persons distributing
the on-site sewage disposal system additive product
in Washington state. Do not list product retailers.
Provide the following information for each:
Contact person name, mailing address, street
address, city/town, state, zip code, telephone and
fax, with area code, time zone. |
| (PI-1) |
List all physical, chemical, biological, or other
agents which make up the additive and provide
toxicity information for each component (provide
material safety data sheet, if possible). Provide
trade and scientific name and formula of chemical
agents. Specify trade and scientific name(s) of
bacteria and enzymes, and characterization (origin,
native occurrence, pathogenicity, etc.). Report
formulation in "% by weight," including inert and
active ingredients, and trace amounts, if any, of
prohibited ingredients (WAC 246-273-050).
|
| (PI-2) |
Describe the anticipated use of the additive in the
on-site sewage system. Include in the description
where and how the product is to be applied, the
frequency of application, who will perform the
application, and the amount and/or concentration of
the product per application. For additives with
chemical constituents, indicate the amount and/or
concentration of each chemical constituent applied
and resulting from application of the product.
|
| (PI-3) |
Describe the function of the additive within the
on-site sewage disposal system and explain in detail
how the additive achieves this function.
|
| (PI-4) |
List all known reactions and by-products produced by
the use of the additive including:
|
|
• The product's effect on bacteria normally found in
a septic tank or aerobic treatment device and the
soil surrounding a subsurface drainfield, and in the
treatment media of a sand filter or sand mound
system; and
|
|
• pH range adjustment in all parts of an on-site
sewage disposal system.
|
| (PI-5) |
Provide any known or projected limitation on the use
of the on-site sewage disposal system additive.
|
| (PI-6) |
Provide reports of any available studies on the use
of the on-site sewage disposal system additive to
support the responses to questions PI-1 through PI-5
and to demonstrate the product's safety (lack of
harm) to the public health, water quality, on-site
sewage system components and function. Include
monitoring reports and data from actual field or
laboratory-based on-site sewage system studies.
|
| (PI-7) |
Attach any formal approvals or other acceptances
from other jurisdictions (private sector, state, or
federal) for use of the on-site sewage disposal
system additive.
|
| (C-1) |
The following statement must be included as part of
a complete application: |
|
"I certify that I represent (INSERT MANUFACTURING COMPANY
NAME), that I am authorized to prepare, or direct the
preparation of, this application, and that the
product presented for review and approval contains
no prohibited ingredients (WAC 246-273-050). I
attest, under penalty of law, that this document and
all attachments, to the best of my knowledge and
belief, are true, accurate, and complete."
|
| (C-2) |
Lines or space must be provided for the applicant's
signature, printed name of preparer (if different
than the applicant), preparer's signature (if
needed) and date. |