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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