[LSRP LETTERHEAD] 

[DATE] 
[NAME AND ADDRESS OF HOLDER OF REMEDIATION TRUST FUND/LINE OF CREDIT] 

RE: 	[NAME OF SITE] 
SRP and RFS Program Interest #________ 
ISRA Case E_____ 
Authorization for disbursement of funds from  [REMEDIATION TRUST FUND or LINE OF CREDIT] 
[Account Number] 

Dear ______: 

This is to advise you I am the Licensed Site Remediation Professional of record for this site. Pursuant to paragraph ____ of the [REMEDIATION TRUST FUND/LINE OF CREDIT], I am authorized to request that you disburse funds from the [REMEDIATION TRUST FUND/LINE OF CREDIT] referenced above to pay for the cost of remediation of the site pursuant to N.J.A.C. 7:26C-5.12(a). 

Please disburse funds held in the [REMEDIATION TRUST FUND/LINE OF CREDIT] on behalf of [NAME OF CASE] as follows: 

1. $______ made payable to [ENTITY TO WHOM PAYMENT SHOULD BE MADE] and remitted to: 
[NAME AND ADDRESS TO WHOM PAYMENT SHOULD BE REMITTED] 

2. $______ made payable to [ENTITY TO WHOM PAYMENT SHOULD BE MADE] and remitted to: 
[NAME AND ADDRESS TO WHOM PAYMENT SHOULD BE REMITTED] 

I certify that these costs represent actual remediation costs of the case which have been incurred or which will be incurred. I further certify that I have not made a request to use these funds in the past three months. 

Sincerely, 					Sincerely.

Signature of LSRP				Signature of Person Responsible for Remediation

C: 	Attn:  Remediation Funding Source Coordinator
New Jersey Department of Environmental Protection
Site Remediation and Waste Management Program
Remediation Funding Source Unit
Mail Code 401-06X
P.O. Box 420
401 East State Street
Trenton, NJ  08625-0420