Class I SFB - WV Department of Environmental Protection

[Pages:1]Class I SFB

PERMIT APPLICATION NO. ____________________

STATEMENT FOR BILLING

The _____________________________________________, of which I am an authorized (name of company or facility)

Representative, has applied for a West Virginia National Pollutant Discharge Elimination System

permit from the West Virginia Department of Environmental Protection, Division of Water and Waste

Management. Under the West Virginia Legislative Rules, title 47, Series 10, Section 12.1.c.2, the

costs of publishing a Class I legal advertisement are to be Paid by the applicant who must also send the

certificate of publication to the Division of Water and Waste Management within twenty (20) days

after publication.

The ______________________________________________, hereby agrees to pay the cost of

name of company or facility

such legal advertisement. The publishing newspaper should send the certificate of publication and bill

to:

__________________________________________________________________________________

Company or facility name and address

__________________________________________________________________________________

_____________________________ authorized representative

________________________________________

area code

phone number

Sworn and subscribed to before

me this _______ day of

________________, 20_____.

_________________________ Notary Public

_________________________ Commission Expires

________________________________________ Signature of Authorized Representative

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