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

New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION – SUBROGATION OF RIGHTS – PART III 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 hereby subrogate to the New Jersey Department of Environmental Protection all rights to recover remediation costs from an insurance carrier, discharger, or person in any way responsible for a hazardous substance discharge pursuant to subsection c. of section 8 of P.L. 1976, c. 141 (C.58:10-23.11g) and who does not have a defense to liability pursuant to subsection d. of that section, upon the failure of the recipient to repay the financial assistance to the State. I further certify that I have not relinquished, impaired, or waived, and do not intend to relinquish, impair, or waive, any right by the State to recover the costs of the remediation against an insurance carrier, discharger, or person in any way responsible for a hazardous substance pursuant to subsection c. of section 8 of P.L. 1976, c.141 (C.58:10-23.11g). Signature Name/Title Township of West Orange Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Part III Page 1 of 1 Version 1.3 12/11/13