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Get Withdrawal Form SFA-004

P.E. CERTIFICATION
SANITARY LANDFILL CLOSURE/POST-CLOSURE

I, __________________________________, a Professional Engineer registered in the State of New Jersey, License No. ____________________, hereby certify that the materials received and /or the services provided in the attached invoices as listed below have been used and or provided at the ____________________________________ Sanitary Landfill. I certify that these materials and / or services are required by and are consistent with the Closure and Post-Closure Plan as approved by the Department of Environmental Protection on ____________.

I further certify, under penalty of law, that I have personally examined and am familiar with the information submitted in this document and all attachments, and that based on my inquiry of those individuals immediately responsible for obtaining the information the attached invoices are reasonable, true, accurate and complete. I am aware that there are significant penalties for submitting false information.

By: ________________________________________

Print Name:________________________________________

Title:_______________________________________


Date: ____________________   (SEAL)



Vendor Name
Invoice No
Date
Amount
       

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Copyright © State of New Jersey, 1996-2002
Department of Environmental Protection
P. O. Box 402
Trenton, NJ 08625-0402

Last Updated: March 3, 2005