Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. In Part A, fill in the facility information, including the permit number, facility name, county, physical address, and contact information such as telephone number and email address.
3. Move to Part B and provide the owner's information, including their name, mailing address, telephone number, and email address.
4. If the facility contact is the same as the owner, indicate this in Part C. Otherwise, fill in the name, title, mailing address, telephone number, and email address of the designated facility contact.
5. In Part D, select the appropriate reason for the waiver request. You can check multiple boxes if applicable and provide additional justification if 'Other' is selected.
6. In Part E, complete the certification by typing or printing your name, signing, and including your official title. Ensure to fill in your telephone number and the date signed.
7. Once all sections are completed, review the form for accuracy. Save your changes, download, print, or share the form as necessary.

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