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MONTANA DEPARTMENT OF ENVIRONMENTAL QUALITY MUNICIPAL FACILITIES EXCLUSION Subdivision Name: Number of lots/parcels/units: Geocode: (this can be found at http://svc.mt.gov/msl/mtcadastral) Are main extensions necessary to serve the subdivision? Yes No If yes, have plans for the mains been submitted for review? Yes No How will construction of the facilities be financed? Owner Information: Owner(s) Name: Print name of owner(s) Signature of all owners of record Address: Street or PO Box, City, State, Zip Code Email: Phone: Consultant Information: Company and Address: Email: Phone: Eligibility Requirements: All of the following criteria must be met: _ The project must be provided with adequate municipal water and sewer, solid waste disposal and the municipality must review storm water plans. _ All the mains necessary to serve the subdivision must be municipality owned, operated and maintained. Privately owned mains or lift stations make the project ineligible for this exemption. _ The municipality must be a 1st or 2nd class municipality as described in MCA 7-4-111 or covered under a growth policy pursuant to Title 76, chapter 1. The project must be one of the following (check applicable box): _ A new division subject to review under the Montana Subdivision and Platting Act, or _ Previously divided parcels recorded with Sanitary Restrictions prior to July 1, 1973 or _ Divisions or parcels of land that are exempt from Montana Subdivision and Platting Act review under 76-3-203 or 76-3-207 or Form continues on next page Submittal Requirements: All of the following items must be submitted: ---PAGE BREAK--- _ This form, signed by the property owner, and the municipalities’ representative. _ Copy of Preliminary Plat, COS, Amended Plat, Unit Declaration or Exemption Certificate. The Plat, COS, Am Plat, Unit Declaration or Exception Certificate must contain the exemption 76-4-125 (ii) or (iii). If using item (iii), the Plat, COS, Am Plat, Unit Declaration or Exemption Certificate must also contain the appropriate Platting Act exemption. _ Vicinity map showing project location. _ Applicable zoning ordinances in effect on file _ Copy of growth policy, if applicable on file _ $120 processing fee Certification: I hereby certify that I am licensed to practice engineering in the State of Montana, I am employed directly or retained by the municipality providing service and am authorized to sign on behalf of the municipality. In addition, I hereby certify that: 1. The existing water and wastewater systems are in compliance with the provisions of Title 75, chapters 5 and 6, and 2. The water and wastewater systems have adequate capacity to meet the needs of the project, and 3. The municipality has or will review plans to ensure adequate storm water drainage and adequate solid waste disposal. (Signature of Professional Engineer) (Date Signed) Montana P.E. Number PE Stamp Send to: MTDEQ Subdivisions PO Box 200901 Helena MT 59620-0901 Revised 8/22/2022