240-25 Exibit A and B.pdf

WQM003-T State of New Jersey Department of Environmental Protection Division of Water Quality INSTRUCTIONS FOR COMPLETING FORM WQM003-T 1. General Information – Provide the applicant/owner/operator name, facility/site/project name, and facility/site/project address. The information provided in this section should match the information provided on the TWA-1 form accompanying this form as part of the application package. 2. Certification Checklist – Complete this section in its entirety, identifying which certifications have been submitted with this form and, for certifications A and C, the number of certifications that were submitted. For certification applicability, refer to the below instructions. Certification A: Governing Body Consistent with N.J.A.C. 7:14A-22.6(a)5 and 22.8(a)3, consent from the affected municipality (i.e. governing body) regarding the project must accompany TWA applications. Note: This certification is required for all TWA applications. For this certification, provide the name of the facility/site/project and the name of the municipality or municipal authority. In addition, the authorized representative must provide the necessary certifying information. This information includes their signature, date of signature, printed name, and position. This section must also include the resolution number and date authorizing the representative to certify for the governing body. The resolution must be submitted with this form. If no such resolution granting authority to sign exists, the full resolution, consenting to the project, must be submitted with this form. Important Note: A separate Certification A must be submitted for each municipality (governing body) impacted by the project. Certification B: Sewage Authority Consistent with N.J.A.C. 7:14A-22.6(a)5 and 22.8(a)3, consent from the affected sewage authority regarding the project must accompany TWA applications. Note: This certification must be completed when a sewerage entity (for example, sewerage authority, utilities authority, municipal utilities authority, joint meeting, etc.) has responsibility for regulating the construction and operation of wastewater treatment and conveyance facilities within the municipality. When a sewage authority is not related to the project, this certification is not required. For this certification, provide the name of the facility/site/project and the

lities within the municipality. When a sewage authority is not related to the project, this certification is not required. For this certification, provide the name of the facility/site/project and the name of the agency. In addition, the authorized representative must provide the necessary certifying information. This information includes their signature, date of signature, printed name, and position. This section must also include the resolution number and date authorizing the representative to certify for the sewage authority. The resolution must be submitted with this form. If no such resolution granting authority to sign exists, the full resolution, consenting to the project, must be submitted with this form. Certification C: Wastewater Conveyance System Owner Consistent with N.J.A.C. 7:14A-22.6(a)5 and 22.8(a)3, consent from the owner(s) of the applicable wastewater conveyance system(s) associated with the project must accompany TWA applications. Note: This section must be completed by the owner/operator of the wastewater conveyance system into which the project named herein will directly connect. The owner is typically a municipality or authority. For this certification, provide the name of the facility/site/project and the wastewater conveyance system owner. In addition, the authorized representative for the owner must provide the necessary certifying information. This information includes their signature, date of signature, printed name, and position. This section must also include the resolution number and date authorizing the representative to certify for the wastewater conveyance system owner. The resolution must be submitted with this form. If no such resolution granting authority to sign exists, the full resolution, consenting to the project, must be submitted with this form. Last Revised: 8/29/2023 Instructions Page 1 of 2