PFAS ASSESSMENT PROJECT

Access Permission Not Granted Form

Project Site ID
Municipality
Street Address
Tax Map ID
Property Owner
Owner’s Mailing Address
Owner’s Authorized Representative
Contact Name
Contact Phone Number
Contact Email

Maine Public Law 2021, Chapter 478, An Act to Investigate Perfluoroalkyl and Polyfluoroalkyl Substance Contamination of Land and Groundwater was enacted on July 15, 2021 and requires the Maine Department of Environmental Protection (Department) to sample and test soil and groundwater in your area for per- and polyfluoroalkyl substances (PFAS).

By signing this form, the property owner (Owner) or Owner’s authorized representative (Representative) hereby denies permission to the Department, its contractor(s), or its agent(s), to enter the above property (Property), (identified by Tax Map ID and/or Street Address), residence, and/or business, to collect samples pursuant to Maine Public Law 2021, Chapter 478.

The person signing this form:

Represents that they are duly authorized to sign this form.

Has been provided with information about PFAS from the Maine Department of Health and Human Services, Center for Disease Control and Prevention.

Acknowledges that the Department may use its right of inspection and entry authority under 38 M.R.S. §347-C if the Department in consultation with the Maine State Legislature determines that obtaining the data is critical to the Department’s investigation of PFAS in Maine’s environment and in protecting public health and the environment.

Permission Denied (Please check box)

Name (printed):_________________________________________________________

Signature:_____________________________________________________________

Date:___________________

PLEASE RETURN FORM BY EMAIL OR POSTAL MAIL TO:

PFAS Assessment Project

Bureau of Remediation and Waste Management

Maine Department of Environmental Protection

17 State House Station

Augusta ME 04333-0017

pfas.dep@maine.gov