Nevada Division of Environmental Protection | NDEP
(Date) (CEM Project No. - Not required)Nevada Division of Environmental ProtectionBureau of Corrective Actions - Petroleum Fund901 S. Stewart Street, Suite 4001?Carson City, NV 89701?Re:Proof of Payment Affidavit for Claim (Claim #)(Facility Name, Facility Address or Location Description, City), NVFacility ID (X-XXXXXX), Petroleum Fund Case No. (XXXXXXXXXX)Petroleum Fund Staff:This letter is being provided to the Nevada Petroleum Fund on behalf of (Claimant’s Name) to confirm receipt of payment for corrective action activities that have occurred at the subject facility under the subject claim number. The payment amount of (enter amount received) was applied to CEM invoice numbers(s) (list CEM invoice number(s)). Furthermore, all services billed through the CEM invoice(s) have been paid in accordance with NAC 445C.310. Record of payment for non-CEM services will be maintained for the project in accordance with NAC 459.9729.1(i) and can be made available to Fund staff upon request.Should you have any questions regarding this letter, please do not hesitate to contact (Consulting Firm Name) at (phone number).Sincerely,(CEM hand written signature)(CEM Name )(Title)(CEM License #)(Contact Information)JURAT: I, (CEM Name), hereby certify that I am responsible for the services described in this document and for thepreparation of this document. The services described in this document have been provided in a manner consistentwith the current standards of the profession and to the best of my knowledge comply with all applicable federal, state, and local statutes, regulations, and ordinances. ................
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