Laserfiche WebLink
V.Affidavit <br /> I/We(Check the box that applies) <br /> DI I the owner(s)and/or operators(s)of underground storage tank(s), <br /> 0 r'the current landowner(s)who is(are)not owner(s)or operator(s)of underground storage tank(s),contributing to an occurrence(s)of <br /> petroleum contamination in soil and/or groundwater.The contamination occurred at the following address: <br /> Street 617 S Fifth Street <br /> City Sanford ,NC Zip 27330 County Lee <br /> A. have not willfully violated any substantive law, rule, or regulation applicable to underground storage tanks (USTs) and intended to <br /> prevent or mitigate discharges or releases or to facilitate the early detection of discharges or releases; <br /> B. have not caused or contributed to the discharge or release due to willful or wanton misconduct; <br /> C. have paid any annual operating fees due pursuant to G.S. 143-215.94C; <br /> D. have identified and fully disclosed any fee, commission,percentage,gift,or other consideration which any owner,lessee,or operator <br /> and the person responsible for conducting the site rehabilitation has or will receive as a result of his employment of a person, <br /> company,corporation,individual,or firm for purposes of conducting site rehabilitation; <br /> E. understand that the Fund is only for reimbursement of actual costs expended for cleanup of releases and discharges of petroleum from <br /> underground storage tanks; <br /> F. understand that the owner or operator is required to comply with all statutes and rules relating to the subject cleanup action regardless <br /> of eligibility for any reimbursement from the Fund; <br /> G. understand that reimbursement from the Fund for cleanup costs does not in any way represent a determination by the Department that <br /> the subject cleanup is being performed in compliance with all applicable statutes and rules; <br /> H. understand that the applicable deductible(s)per occurrence or site must be met prior to any monies being reimbursed from the Fund; <br /> I. understand that reimbursement from the Fund shall only be for costs directly related to the subject cleanup and determined to be <br /> reasonable and necessary by the Department, that reimbursement requests shall be subject to audit by the Department, and that the <br /> Department may seek recovery of any reimbursed funds relating to ineligible costs; <br /> J. understand that submission of a false statement,representation,or documentation to the Department under Article 21A of Chapter 143 <br /> of the General Statutes,or under any rules adopted shall be guilty of a misdemeanor,punished by a fine not to exceed fifteen thousand <br /> dollars ($15,000),or by imprisonment not to exceed sixty days or both, and may result in ineligibility for reimbursement from the <br /> Funds; <br /> K. hereby authorize to the Department of Environmental Quality to contact and obtain any information deemed necessary from any of the <br /> above-named parties for the purpose of determining applicant eligibility and the amount eligible for reimbursement from the Leaking <br /> Petroleum Underground Storage Tank Cleanup Fund; <br /> L. hereby declare under penalty of perjury that all facts and statements set forth herein and in all attachments are true and accurate; <br /> M. also declare that if funds are received after completion of this Certification, I (we) will notify the Department promptly. If <br /> reimbursement is received from the Department,and we have also received funds from other sources,I(we)will remit to the Fund the <br /> amount determined by the Department to be double payment;and, <br /> N. understand that any misrepresentation made on this form,or failure to disclose funds received or funds which may be received in the <br /> future,may result in ineligibility for reimbursement from the Fund. <br /> Amy Dalrymple Chair,Lee County Board of Commissioners Lee County General Services <br /> Applicant name/Signatory* Title Company <br /> 617 S Fifth Street 919-718-4622 ext 5380 <br /> Applic t address Applicant Telephone number <br /> /jA _ I7_ �1O O adalrymple@leecountync.gov/ <br /> O( of ruscell spivey©leacnuntync.gov <br /> Applican signature Date E-mail <br /> COUNTY OF Let STATE OF 1\1 O(-!h �a�Dl i na <br /> I certify that the following .erson(s)personally appeared before me this day,each acknowledging to m- that he or she si• ed 1 t� regoing <br /> document: ' 1, ll. P1 ►s 91 / 1 ' .. 1... Gra a .. !!/ll 1 (L 0"1 R�4� �// <br /> (Nota Public to writ n a.plicant name) (1 escribe if signed indivis ally or in representative capac\�) \ � ii,'i/ <br /> WITNESS my hand and officials 1,this 4h da of kb(J2)( ,20.20 4�' Notary Public<9c <br /> Lee <br /> Notary Public My commission expires 1/I o/aoa. County <br /> - My Comm. Exp. _— <br /> *Attach copy of power of attorney or executor document. '1- 01-16 2023 . <br /> ///�ti CAR,' \`\\. <br /> 5 DWM/UST V.8/1/19 <br />