ARM-ACM-201 (Rev
ARM-ACM-335.docx rev.01/2021-66264699000Wisconsin Department of Agriculture, Trade and Consumer ProtectionDivision of Agricultural Resource ManagementBureau of Agrichemical ManagementPO Box 8911, Madison WI 53708-8911Phone: (608) 224-4522OFFICE USE ONLYApplication Number: FORMTEXT ?????(s. 94.73, Wis. Stats.)ACCP MULTIPLE RESPONSIBLE PERSONS FORMPrior to filing an application for reimbursement, a reasonable effort must be made to notify every potentially responsible person who may have incurred corrective action costs related to the discharge site. All responsible persons filing for reimbursement at this site must reach agreement and specify to the Department how the deductible will be met and how the reimbursement payments should be divided. See s. ATCP 35.20, Wis. Adm. Code, for further clarification.If there are no other responsible persons to notify, please check here FORMCHECKBOX and sign at the bottom.If there are other responsible persons, please complete the following:OTHER RESPONSIBLE PERSON 1NAME FORMTEXT ?????PHONE # ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????EMAIL FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP CODE FORMTEXT ?????OTHER RESPONSIBLE PERSON 2NAME FORMTEXT ?????PHONE # ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????EMAIL FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP CODE FORMTEXT ?????OTHER RESPONSIBLE PERSON 3NAME FORMTEXT ?????PHONE # ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????EMAIL FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP CODE FORMTEXT ?????OTHER RESPONSIBLE PERSON 4NAME FORMTEXT ?????PHONE # ( FORMTEXT ??? ) FORMTEXT ??? - FORMTEXT ????EMAIL FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ??ZIP CODE FORMTEXT ?????The undersigned states that a reasonable effort has been made to notify every potentially responsible person and that each person listed above was notified this application is being filed. The undersigned is aware that by not attempting to notify all potentially responsible persons, the undersigned may become liable to them for any eligible costs they were not reimbursed. See s. ATCP 35.20, Wis. Adm. Code, for further explanation. FORMCHECKBOX The other responsible persons identified above are not submitting costs with this reimbursement application. FORMCHECKBOX The other responsible persons identified above are submitting costs with this reimbursement application. FORMTEXT ????? FORMTEXT ?????SIGNATURE OF APPLICANTDATEPersonal information that you provide may be used for purposes other than that for which it was originally collected. Wis. Stat. s. 15.04(1)(m). ................
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