Fill and Sign the Payment and Policy Notification Hinds Community College Hindscc Form

New Jersey Department of Environmental Protection Site Remediation Program HAZARDOUS DISCHARGE SITE REMEDIATION FUND – PART I LSRP Subsurface Evaluator (for UHOT cases only) Date Stamp (For Department use only) SECTION A. REQUESTED FUNDING TYPE AND AMOUNT PLEASE CHECK HERE IF INITIAL APPLICATION HAS BEEN SUBMITTED Public Entity Brownfield Development Area Grant ...........................................$ PA/SI/RI Grant .............................................................................$ 75% Recreation and Conservation Grant ....................................$ 75% Renewable Energy Grant ....................................................$ 50% Affordable Housing Grant ....................................................$ 25% Matching Grant Remedial Action(LR/UR) ...........................$ 25% Matching Grant Innovative Technology ...............................$ Loan .............................................................................................$ Private Entity 50% Innocent Party Grant ...........................................................$ 25% Matching Grant Remedial Action(LR/UR) ...........................$ 25% Matching Grant Innovative Technology ...............................$ Loan .............................................................................................$ Non-Profit PA/SI/RI Grant .............................................................................$ SECTION B. APPLICANT INFORMATION Name: Address: City: State: County: Phone Number: Zip Code: Ext: Fax: Email Address: Individual: Social Security Number: Businesses: Tax ID Number: SIC: NIAC: SECTION C. CONTACT INFORMATION Check here if contact information is the same as Section B above (proceed to Section D) Contact Person: Title: Affiliation: Address: City/Town: Phone Number: State: Ext: Zip Code: Fax: Email Address: HDSRF Application Version 1.3 12/11/13 Part I Page 1 of 4 SECTION D. SITE OWNERSHIP INFORMATION Check here if site ownership information is the same as Section B above (proceed to Section E) Name of Site Owner: Address: City/Town: State: Zip Code: SECTION E. SITE INFORMATION (location where remediation will be conducted) Name of Site (as identified on NJDEP’s Known Contaminated Site List): PI (Program Interest) Number: Acreage: Other Site Names (A.K.A.): Address: City: State: County: Zip Code: Municipal Block(s) and Lot(s): SECTION F. EXISTING CASE Have remediation activities been performed at the site? ...................................................................................... Yes No If “Yes,” provide the name of the site: ______________________________________________________________ SRP Preferred ID No.: _______________________ Case Tracking No.: __________________________ SECTION G. VIOLATIONS, PENALTIES & FEES Any applicant that is not in compliance with all applicable DEP regulation must submit a written description and explanation for noncompliance including a list of all violations and outstanding fees and penalties to be provided below. Applicant’s must specify whether the violations, fees or penalties are currently being contested in a manner prescribed by law and whether the violations, fees and penalties resulted from a lack of financial resources to perform required remediation. HDSRF Application Version 1.3 12/11/13 Part I Page 2 of 4 SECTION H. OTHER FUNDING SOURCES Indicate all other sources of financial assistance sought for the remediation of the site. Check here if no other funding sought Insurance Coverage UST Fund 75% Brownfield Reimbursement Entity(s) responsible for conducting the remediation NJRA Brownfield Redevelopment Initiative Green Acres NJ Environmental Infrastructure Trust Other: ____________________________________________ SECTION I. WORK PROPOSAL Attach Work Proposal to application. Name of Company Preparing the Work Proposal: Preparer Name: Phone: Email Address: SECTION J. COST ESTIMATE Attach Detailed Cost Estimate to application. SECTION K. DEMONSTRATION OF NEED FOR LOAN APPLICANTS Loan applicants must demonstrate that they cannot obtain commercial funding by submitting denial letters from two lending institutions. Provide letters with application. SECTION L. FINANCIAL INFORMATION (Private Entities, Except for Innocent Party Applicants) Homeowners must submit Federal tax returns for the last three years. Businesses and private matching grant applicants must attach business, as well as personal, financial statements for the last three years. Provide financial information with application. HDSRF Application Version 1.3 12/11/13 Part I Page 3 of 4 SECTION M. LICENSED SITE REMEDIATION PROFESSIONAL INFORMATION AND STATEMENT LSRP ID Number: First Name: Last Name: Phone Number: Ext: Fax: Mailing Address: City/Town: State: Zip Code: Email Address: This statement shall be signed by the LSRP who is submitting this notification in accordance with SRRA Section 16 d. and Section 30 b.2. I certify that I am a Licensed Site Remediation Professional authorized pursuant to N.J.S.A. 58:10C to conduct business in New Jersey. As the Licensed Site Remediation Professional of record for this remediation, I: [SELECT ONE OR BOTH OF THE FOLLOWING AS APPLICABLE]: directly oversaw and supervised all of the referenced remediation, and\or personally reviewed and accepted all of the referenced remediation presented herein. I believe that the information contained herein, and including all attached documents, is true, accurate and complete. It is my independent professional judgment and opinion that the remediation conducted at this site, as reflected in this submission to the Department, conforms to, and is consistent with, the remediation requirements in N.J.S.A. 58:10C-14. My conduct and decisions in this matter were made upon the exercise of reasonable care and diligence, and by applying the knowledge and skill ordinarily exercised by licensed site remediation professionals practicing in good standing, in accordance with N.J.S.A. 58:10C-16, in the State of New Jersey at the time I performed these professional services. I am aware pursuant to N.J.S.A. 58:10C-17 that for purposely, knowingly or recklessly submitting false statement, representation or certification in any document or information submitted to the board or Department, etc., that there are significant civil, administrative and criminal penalties, including license revocation or suspension, fines and being punished by imprisonment for conviction of a crime of the third degree. LSRP Signature: Date: LSRP Name/Title: Company Name: 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 Version 1.3 12/11/13 Part I Page 4L of 4 SECTION M. SUBSURFACE EVALUATOR INFORMATION AND STATEMENT 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: Phone Number: Ext: Signature: Zip Code: Fax: 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 Version 1.3 12/11/13 Part I Page 4SE of 4 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 Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Version 1.3 12/11/13 Part II Page 1 of 1 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 Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Version 1.3 12/11/13 Part III Page 1 of 1 New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION – INNOCENT PARTY GRANT CERTIFICATION – PART IV THIS CERTIFICATION IS REQUIRED FOR ALL APPLICANTS APPLYING FOR AN INNOCENT PARTY GRANT 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 other than above (i.e. homeowner/individual), the person with legal responsibility for the site. I hereby certify that A) I (the applicant) acquired the property prior to December 31, 1983; B) I (the applicant) own and will continue to own the property until NJEDA approves the grant; C) The hazardous substance or hazardous waste that was discharged at the property was not used by the me (the applicant) or by any person with permission to use the property; and D) I (the applicant), or any person I gave permission to use the property, did not discharge any hazardous substance or hazardous waste at an area where a discharge is or has been discovered. Signature Name/Title Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Version 1.3 12/11/13 Part IV Page 1 of 1 New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION – 25% MATCHING GRANT REMEDIAL ACTION CERTIFICATION – PART V THIS CERTIFICATION IS REQUIRED FOR ALL PRIVATE ENTITY APPLICANTS APPLYING FOR A 25% MATCHING RA GRANT 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 other than above (i.e. homeowner/individual), the person with legal responsibility for the site. I hereby certify that A) The requestor has a net worth of not more than $2,000,000 at the time the relevant costs are incurred; and B) The requestor will implement a remedial action using an innovative technology or a limited restricted or unrestricted use remedial action. Signature Name/Title Company Sworn to and Subscribed Before Me On this date of Notary HDSRF Application Version 1.3 12/11/13 Part V Page 1 of 1 New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION – MUNICIPAL QUESTIONNAIRE – PART VI THIS INFORMATION IS REQUIRED FOR ALL PUBLIC ENTITIES APPLICANTS In order to expedite the processing of grant or loan application for public entities at the NJEDA, complete this Preliminary Questionnaire and return it to the NJDEP as part of the HDSRF application. NJDEP will forward this information to the NJEDA once your application has been approved. If you have any questions about available financial assistance, call the NJEDA at (609) 341-2723. 1. Applicant: Project Name: 2. Indicate the estimated project start date. Start Date: 3. List the current owner of the project site: 4. If you are not the owner, do you hold a tax sales certificate for the property? .............................................. Yes No When was the tax sale certificate obtained? Date: ______________________ PROVIDE A COPY OF PROPERTY OWNERSHIP, SUCH AS TAX SALE CERTIFICATE, FORECLOSURE PAPERS, ETC. WITH THIS APPLICATION. If the municipality does not currently own the property or hold a tax sale certificate, has the municipality passed a resolution indicating an intent to acquire the property? ............................................. Yes No When was the resolution passed? Date: ____________________ 5. Describe any pending or threatened litigation related to the project site. 6. Describe any other pending issues that could delay grant/loan closing. 7. If the financial assistance for which you are applying will not cover the full cost of your project, such as the removal of underground storage tanks, identify other funding sources: Issuance of Bonds $ ____________________ Capital Budget Expenditure $ ____________________ Other, please describe: ______________________________________________________________ HDSRF Application Version 1.3 12/11/13 Part VI Page 1 of 2 LOAN APPLICANTS, ANSWER QUESTIONS 8 THROUGH 11: 8. Indicate the length of term, up to ten years, you desire for this loan. (Note that this term must be coterminous with all additional project financing.) ___________ Years 9. Indicate if your municipality will need Local Finance Board Approval to participate in this program (i.e. are you within your legal debt limit?) ........................................................................................................ Yes No 10. If you currently hold a tax sale certificate or have acquired the site through foreclosure, do you intend to sell the remediated property and return it to your tax rolls within the next two years?................. Yes No 11. If you answered yes to question 10, indicate whether you would like a moratorium on principal and interest payments up to a maximum of two years. ................................................................. Yes No If “Yes,” please state reason below. If “Yes,” I request a payment moratorium of ____________ years 12. Provide additional comments in the space below. Certification: By their signature below, the undersigned, a duly authorized representative of the above unit of local government, hereby certifies on behalf of the local government that the information contained herein is true, complete and correct in all respects as of the date hereof. Signature: Date: Name (print): Title: HDSRF Application Version 1.3 12/11/13 Part VI Page 2 of 2 New Jersey Department of Environmental Protection Site Remediation Program HDSRF APPLICATION CHECKLIST – PART VII This following checklist has been provided to assist you in preparing a HDSRF application for each specific grant and/or loan offered by the program. Please review the checklist for the applicable grant and/or loan to verify all required documentation has been included as part of the application package. PUBLIC ENTITIES Brownfield Development Area (BDA) Grant HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge One original and one copy of the HDSRF application packet PA/SI/RI Grant HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Proof of ownership interest (tax sale certificate, deed, or resolution to acquire property by voluntary conveyance) Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/ suspected discharge Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) One original and one copy of the HDSRF application packet 75% Recreation and Conservation Grant HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge Documentation indicating the property is to be preserved for recreation/conservation by conveyance of a development easement, conservation easement, or other restriction/easement permanently restricting development Comprehensive plan for the development or redevelopment of the subject property One original and one copy of the HDSRF application packet 75% Renewable Energy Grant HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge HDSRF Application Version 1.3 12/11/13 Part VII Page 1 of 3 75% Renewable Energy Grant (continued) Documentation indicating the property is to be redeveloped for a project that will generate renewable energy. Comprehensive plan for the development or redevelopment of the subject property One original and one copy of the HDSRF application packet 50% Affordable Housing HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge Copy of the deed for the property indicating the inclusion of the appropriate restrictions for Affordable Housing Comprehensive plan for the development or redevelopment of the subject property One original and one copy of the HDSRF application packet 25% RA Matching Grants Remedial Action (Limited Restricted Use/ Unrestricted) HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal with detailed description of remedial action and itemized cost estimate Proof of ownership of the subject property (copy of the Deed) Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) One original and one copy of the HDSRF application packet 25% Matching RA Grants Innovative Technology HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal with description of the innovative technology and itemized cost estimate Proof of ownership of the subject property (copy of the Deed) Resolution that public entity authorized to apply to HDSRF for the remediation of a discharge/suspected discharge Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) One original and one copy of the HDSRF application packet Loans HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Municipal Questionnaire (Part VI) Detailed remediation Work Proposal and itemized cost estimate Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) One original and one copy of the HDSRF application packet HDSRF Application Version 1.3 12/11/13 Part VII Page 2 of 3 PRIVATE ENTITIES Innocent Party Grants HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) HDSRF Innocent Party Grant Certification (Part IV) Proof of ownership of the subject property (copy of the Deed) Detailed remediation Work Proposal with detailed description of remediation and itemized cost estimate One original and one copy of the HDSRF application packet 25% Matching Grants Remedial Action (Limited Restricted Use/ Unrestricted) HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) HDSRF 25% Matching Grant RA Certification (Part V) Proof of ownership of the subject property (copy of the Deed) Business and personal financial statements for the last three years Detailed remediation Work Proposal with detailed description of remedial action and itemized cost estimate One original and one copy of the HDSRF application packet 25% Matching Grants Innovative Technology HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) HDSRF 25% Matching Grant RA Certification (Part V) Proof of ownership of the subject property (copy of the Deed) Business and personal financial statements for the last three years Detailed remediation Work Proposal with description of the innovative technology and itemized cost estimate One original and one copy of the HDSRF application packet Loans HDSRF Application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Proof of ownership of the subject property (copy of the Deed) Denial letters from two lending institutions Three previous years of federal tax returns Detailed remediation Work Proposal with detailed description of remediation and itemized cost estimate One original and one copy of the HDSRF application packet NON-PROFIT ORGANIZATIONS PA/SI/RI Grant HDSRF application form (Part I) HDSRF General Certification (Part II) HDSRF Subrogation of Rights (Part III) Proof of ownership interest of the subject property (Deed or resolution to acquire property by voluntary conveyance) Documentation indicating status as a 501(c)3 non-profit organization Detailed remediation Work Proposal with detailed description of remediation and itemized cost estimate Resolution that the non-profit organization is authorized to apply to HDSRF for the remediation of a discharge/suspected discharge Comprehensive redevelopment plan or resolution (indicating a realistic opportunity exists to develop within three years following completion of the remediation) One original and one copy of the HDSRF application packet HDSRF Application Version 1.3 12/11/13 Part VII Page 3 of 3