A petition for waiver filed in accordance with this chapter
must meet the requirements specified herein and must substantially conform to
the following form:
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1. Provide
the name, address, and telephone number of the petitioner (person asking for a
waiver). Also provide the name, address, and telephone number of the
petitioner's legal representative, if applicable, and a statement indicating
the person to whom communications concerning the petition should be
directed.
2. Describe and cite the
specific rule from which a waiver is requested.
3. Describe the specific waiver requested,
including the precise scope and time period for which the waiver will
extend.
4. Explain the relevant
facts and reasons that the petitioner believes justify a
waiver Include in your
answer all of the following:
* Why applying the rule would result in undue hardship to the
petitioner;
* Why waiving the rule would not prejudice the substantial
legal rights of any person;
* Whether the provisions of the rule subject to the waiver
are specifically mandated by statute or another provision of law; and
* How substantially equal protection of public health,
safety, and welfare will be afforded by a means other than that prescribed in
the particular rule for which the waiver is requested.
5. Provide a history of any prior contacts
between the department and petitioner relating to the regulated activity that
would be affected by the waiver.
6.
Provide information known to the petitioner regarding the department's action
in similar cases.
7. Provide the
name, address, and telephone number of any public agency or political
subdivision that also regulates the activity in question or that might be
affected by the granting of the petition.
8. Provide the name, address, and telephone
number of any person or entity that would be adversely affected by the granting
of the waiver
9. Provide the name,
address, and telephone number of any person with knowledge of the relevant
facts relating to the proposed waiver
10. Provide signed releases of information
authorizing persons with knowledge regarding the request to furnish the
department with information relevant to the
waiver.
I hereby attest to the accuracy and truthfulness of the above
information.
________________ ____
Petitioner's signature Date
