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Massachusetts Department of Environmental Protection Bureau of Resource Protection Title 5 ProgramProvisional Use Approval Certification Forms Exhibit A: Certification Statement for System Design
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How to fill out provisional use approval certification

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How to fill out provisional use approval certification

01
Step 1: Obtain the provisional use approval certification form from the relevant authority.
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Step 2: Fill out the required personal and company information accurately.
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Step 3: Provide details of the intended use of the provisionally approved product or service.
04
Step 4: Attach supporting documents, such as product specifications, safety tests, or any other relevant evidence.
05
Step 5: Review the completed form and ensure all information is correct.
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Step 6: Submit the filled-out form along with the necessary fees to the authority for review.
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Step 7: Wait for the authority to evaluate the application and provide approval or further instructions.
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Step 8: Upon receiving approval, follow any additional instructions provided and commence provisionally using the product or service.

Who needs provisional use approval certification?

01
Anyone who intends to provisionally use a product or service that requires approval from the relevant authority needs provisional use approval certification.
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Provisional use approval certification is a document obtained from the relevant authority to temporarily allow the use of a property for a specific purpose.
Property owners or tenants seeking to use a property for a specific purpose are required to file provisional use approval certification.
Provisional use approval certification can be filled out by providing details of the property, proposed use, duration of approval needed, and any additional information requested by the authority.
The purpose of provisional use approval certification is to grant temporary permission for the use of a property for a specific purpose until full approval is obtained.
Information such as property details, proposed use, duration of approval needed, contact information of the applicant, and any other relevant details must be reported on provisional use approval certification.
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