21383 Floating Cabin Wastewater Discharge Certification Form

TVA RESTRICTED INFORMATION

Tennessee Valley Authority
Floating Cabin Wastewater Discharge Certification Form

OMB No. 3316-0060
Exp. Date xx/xx/xxxx

Owner #1 Mailing Information (Required)

Owner #2 Mailing Information

Name

Name

Street

Street

City ____________________ State___________ Zip code

City ____________________ State___________ Zip code

Email Address

Email Address

Home Phone

Home Phone

Mobile Phone

Reservoir:______________________

Mobile Phone

FC-UID:_______________ TVA Permit ID:

Wastewater Discharge Certification
In accordance with 18 CFR 1304.2(d), if construction, maintenance, or operation of the structure for which approval from TVA is sought may result in
any discharge into navigable waters of the United States, the applicant shall also submit with the application a copy of the request for certification
from the state in which such discharge would originate that applicant’s structure will comply with applicable water quality standards. Wastewater
discharges include blackwater (sewage) and graywater (water generated from showers, sinks, etc.).
Does your floating cabin generate blackwater?  No
Does your floating cabin generate other wastewater?

 Yes
 No

Does your floating cabin generate graywater?  No
 Yes

 Yes

If yes, explain: ______________________________________________

Signature (Required)
I certify that I will comply with the conditions of the applicable State of ________________________ water quality certification and TVA’s Section 26a
permit, if granted, which may require no discharge of wastewater.

Date

Owner #1 Name (Printed)

Owner #1 Signature

Date

Owner #2 Name (Printed)

Owner #2 Signature

18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies,
conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false
writing or document knowing same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five
years, or both.
Privacy Act Statement
This information is being requested in accordance with Section 26a of the TVA Act. Disclosure of the information requested is voluntary; however, failure to provide any required information or
documents may result in a delay in processing your application, in your being denied a Section 26a permit, or in your Section 26a permit being revoked. An application that is not complete will be
returned for additional information. TVA uses this information to assess the impact of the proposed project on TVA programs and the environment and to determine if the project can be approved.
Information in the application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information include providing to federal, state, or local agencies,
and to consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services to the program; to respond to a congressional inquiry concerning the
application or Section 26a program; and for oversight or similar purposes, corrective action, litigation or law enforcement.
The information requested in this form becomes part of the Section 26a Permit Application Records Privacy Act System of Records (TVA-36). Authority for maintenance of this system of records is
provided by the Tennessee Valley Authority Act of 1933, 16 U.S.C. 831-831ee.
The information solicited on this form may be made available as a "routine use." A complete list of the routine uses can be found in the system of records notice associated with this form, "Section
26a Permit Application Records, TVA-36." TVA's system of records notices can be found on the TVA website at https://www.tva.com/information/about-the-tva-privacy-program.

Burden Estimate Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget,
Paperwork Reduction Project (3316-0060), Washington, D.C. 20503.

TVA 21383 [xx-xx-2022]

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TVA RESTRICTED INFORMATION