14-18 Exhibit-Application for Discharge Site Remediation Funds from HDSRF.pdf

SECTION M. SUBSURFACE EVALUATOR INFORMATION AND STATEMENT N/A I certify under penalty of law that the work was performed under my oversight and I have reviewed the report and all attached documents, and the submitted information is true, accurate and complete in accordance with the requirements of N.J.A.C. 7:14B and N.J.A.C. 7:26E. I am aware that there are significant civil and criminal penalties for submitting false, inaccurate or incomplete information including fines and/or imprisonment. Name: UST Cert. No.: Firm: Firm’s UST Cert. Number: Firm Address: City/Town: State: Zip Code: Phone Number: Ext: Fax: Signature: Date: No Changes To Contact Information Since Last Submission Completed forms should be sent to: Bureau of Case Assignment & Initial Notice Site Remediation Program NJ Department of Environmental Protection 401-05H PO Box 420 Trenton, NJ 08625-0420 HDSRF Application Part I Page 4SE of 4 Version 1.3 12/11/13