NJDEP-Escrow Withdrawal Form SFA-004

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Get P.E. Certification Statement

______________________________________________________________________________
(FACILITY NAME AND NUMBER)

SFA-004
2/05

SANITARY LANDFILL CLOSURE
REQUEST FOR CLOSURE/POST CLOSURE FUNDS

Note: Closure and Post Closure Costs entered MUST contain both dollars and cents.
Do not round-off any entered amounts.

	PROVISIONS N.J.A.C 7:26-2A-9 (e) &(f)	CLOSURE COSTS	POST-CLOSURE COSTS
i.	Soil Erosion and Sediment Control Plan		NA
ii.	Final Cover		NA
iii.	Final Cover Vegetation		NA
iv.	Maintenance Program for Final Cover and Final Cover Vegetation	NA
v.	Maintenance Program for Side Slopes	NA
vi.	Run On/Run Off Control Program		NA
vii.	Maintenance Program for Run On/Run Off Control Program	NA
viii.	Groundwater Monitoring Wells		NA
ix.	Maintenance Program for Groundwater Monitoring Wells	NA
x.	Groundwater Monitoring In Accordance with N.J.A.C. 7:14A-1	NA
xi.	Methane Gas Venting or Evacuation System		NA
xii	Maintenance Program for Methane Gas Venting or Evacuation System	NA
xiii.	Lechate Collection and/or Control System		NA
xiv.	Maintenance Program for Lachate Collection and/or Control System	NA
xv.	Facility Access Control System		NA
xvi.	Maintenance Program for Facility Access Control System	NA
xvii.	Measures to Conform the Site to Surrounding Areas		NA
xviii.	Maintenance Program for Site Conformance Measures	NA



	TOTAL COSTS

I certify that these expenditures are in accordance with the "Closure and Post Closure Financial Plan" as approved by the Department of Environmental Protection on (date) ___________________________________

______________________________________
Authorized Signature

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Title

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