497—9.6(17A) Content of petition. A petition for waiver shall include the following information where applicable and known to the petitioner:
	1.	The name, address and telephone number of the person for whom a waiver is being requested and the case number of any related contested cases, if applicable.
	2.	A description and citation of the specific rule from which waiver is requested.
	3.	The specific waiver requested, including the precise scope and duration.
	4.	The relevant facts the petitioner believes would justify a waiver under each of the four criteria described in rule 497—9.4(17A). This shall include a signed statement from the petitioner attesting to the accuracy of the facts provided in the petition and a statement of reasons the petitioner believes will justify a waiver.
	5.	A history of any contacts between the board and the petitioner within the past three years relating to the activity affected by the proposed waiver. This shall include any notices of violation whether resolved through administration resolution or a contested case proceeding within the past three years.
	6.	Any information known to the petitioner regarding the board’s treatment of similar cases.
	7.	The name, address and telephone number of any public agency or political subdivision that also regulates the activity in question or that might be affected by the granting of the waiver.
	8.	The name, address and telephone number of any person or entity that would be adversely affected by the granting of the waiver.
	9.	The name, address and telephone number of any person with knowledge of facts relevant to the proposed waiver.
	10.	Signed releases authorizing the persons with knowledge regarding the request to furnish the board with information relevant to the proposed waiver.
[ARC 2138C, IAB 9/16/15, effective 10/21/15]