APPENDIX 5(b)

APPLICATION FORM FOR A DEPARTURE FROM THE REGULATIONS UNDER ARTICLE 5

General

Sanitary Authority:______

Address:______

______

______

Telephone No:______

Fax No.:______

Contact Person:______

Details of Departure

Name of Water Supply[1]:______

Grid Reference of Abstraction Point: ______

Population Served:______

Volume Supplied:______

Present Treatment[2]:______

Parameter Departure being Applied for (please tick all relevant):

Acrylamide / Fluoride
Antimony / Lead
Arsenic / Mercury
Benzene / Nickel
Benzo(a)pyrene / Nitrate
Boron / Nitrite
Bromate / Pesticides
Cadmium / Pesticides-Total
Chromium / Polycyclic Aromatic Hydrocarbons
Copper / Selenium
Cyanide / Tetrachloroethene/Trichloroethene
1,2-dichloroethane / Trihalomethanes
Epichlorohydrin / Vinyl Chloride

Grounds for the Departure:

Please include past monitoring results, geological maps or other information in support of the application including justification of the fact that the supply of water intended for human consumption cannot otherwise be maintained by any other reasonable means.

______

______

Duration of Departure Applied for (not more than 3 years):

______year(s)

Please provide details of other possible alternative sources of water for supply:

______

Assessment of the Impact of the Departure

Please tick (and provide details as appropriate) if any of the following activities are currently using or will be using the water supplied during the duration of the departure:

Hospitals/Medical Centres
Nursing Homes
Schools
Food Production Facilities
Other Sensitive Users (Give details)

______

______

______

______

______

______

Please provide details of how the sanitary authority intends to identify particular population groups for which the departure could present a particular risk and how the sanitary authority intends to ensure that appropriate advice is given to such groups.

______

Please provide information describing how the sanitary authority has satisfied itself that the departure applied for will not constitute a potential danger to human health. This should include evidence that the Health Board has been consulted in relation to the application and that the consent and agreement of the health board in relation to the application being obtained.

Monitoring

Current Monitoring Programme:

Please give details of the current monitoring regime for the above mentioned supply including details of the number of samples currently taken for all parameters with particular reference to the parameter(s) which are the subject of this application. Please provide the results of the previous three years monitoring for the parameter(s) which is the subject of this application (if available).

______

Remedial Action

Please provide a plan of works for remedial action necessary to improve the supply to the point of compliance with the parametric values specified in Table B of Part 1 of the Schedule of the European Communities (Drinking Water) Regulations 2000 within the duration of the departure applied for with particular reference to:

Remedial Action to be carried out.

A timetable for the works.

An estimate for the costs of the works.

Provisions for the review of work to ensure completion before the cessation of the departure applied for.

Please provide details of how the sanitary authority intends to ensure that the population affected by the departure applied for above is promptly informed of the departure and of the conditions governing it.

______

Declaration

I hereby make application for a departure from the parametric values specified in Table B of Part 1 of the Schedule of the European Communities (Drinking Water) Regulations, 2000.

I certify that the information given in the application is truthful, accurate and complete.

Signature:______Date:______

Print Name:______

Title:______

[1] Please insert a map indicating the geographical area to which the water is supplied

[2] Please include detailed site maps including a description of the treatment processes carried out at the abstraction point with particular reference to any parameters that are the subject of this application