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

New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION – GENERAL CERTIFICATION – PART II THIS CERTIFICATION IS REQUIRED TO BE COMPLETED BY ALL APPLICANTS This certification shall be signed as follows: for a corporation, by a principal executive officer, at least the level of vice president; for a partnership, by a general partner; for a sole proprietorship, by the proprietor; for a public entity, the contact person (administrator, township manager, etc.); for other than above (i.e. homeowner/individual), the person with legal responsibility for the site. I certify under penalty of law that I have personally examined and am familiar with the information submitted herein and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate and complete. I am aware that there are significant civil penalties for knowingly submitting false, inaccurate or incomplete information and that I am committing a crime of the fourth degree if I make a written false statement which I do not believe to be true. I am aware that if I knowingly direct or authorize the violation of any statute, I am personally liable for the penalties. Signature Name/Title Township of West Orange Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Part II Page 1 of 1 Version 1.3 12/11/13