What is the asbestos sampling waiver application for?

It is an application for a certificate of waiver from asbestos sampling requirements. The form requests details about the public water supply, asbestos cement pipe, water quality, and any asbestos fiber test results.

Who should complete this application?

The application is for a public water supply owner seeking a waiver. Section A asks for facility and owner information, and Section D includes a certification by the person completing the questionnaire.

Do I need a notary for the asbestos sampling waiver application?

No. This application is signed and dated without a notary. The signer certifies that the information is true; the form does not list a notarized attachment or related step.

How do I submit the asbestos sampling waiver application?

Complete Sections A through D and submit the form to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601. The form also lists a fax number.

Dutchess County, NY · Dutchess County

No notary required

Application for a Certificate of Waiver from Asbestos Sampling Requirement

Public water supply owners use this application to request a Dutchess County waiver from asbestos sampling requirements for their distribution system.

At a glance

Issued by: City of Dutchess County · Dutchess County, Dutchess County, New York
Notarization: Not required: file this form without a notary.
Official source: dutchessny.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This application lets a public water supply owner request a certificate of waiver from asbestos sampling requirements. It asks for facility and distribution system details, information about asbestos cement pipe, available water-quality and laboratory results, and a signed certification. Complete Sections A through D and submit the form to the Dutchess County Department of Health.

Who needs it

Owners of public water supplies seeking a waiver from asbestos sampling requirements for their distribution system should complete this application.

How to submit it

Submit the completed form to the Dutchess County Department of Health, 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601. The form also lists fax number 845-486-3545.

About notarization

This application is signed and dated without a notary; the signer certifies the information is true, and no notarized attachment or related step is listed.

How to submit this form

1
Download the Application
Download the Dutchess County application for a certificate of waiver from asbestos sampling requirements.
2
Complete Sections A Through D
Provide facility and distribution system information, asbestos cement pipe details, available test results, and the signed certification.
3
Gather Supporting Information
Attach additional sheets if needed, laboratory results if applicable, and a sketch or map showing the location of all asbestos cement pipe.
4
Submit to the County
Send the completed application to the Dutchess County Department of Health at the address printed on the form.

Frequently asked questions

What is the asbestos sampling waiver application for?: It is an application for a certificate of waiver from asbestos sampling requirements. The form requests details about the public water supply, asbestos cement pipe, water quality, and any asbestos fiber test results.
Who should complete this application?: The application is for a public water supply owner seeking a waiver. Section A asks for facility and owner information, and Section D includes a certification by the person completing the questionnaire.
Do I need a notary for the asbestos sampling waiver application?: No. This application is signed and dated without a notary. The signer certifies that the information is true; the form does not list a notarized attachment or related step.
How do I submit the asbestos sampling waiver application?: Complete Sections A through D and submit the form to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601. The form also lists a fax number.

Need something notarized?

This Application for a Certificate of Waiver from Asbestos Sampling Requirement doesn’t need a notary, but if you have another Dutchess County form that does, a commissioned online notary can help.