1160 Environmental Consultant Disclosure Statement



Proposed Project/Action Information:Project Title:Project Address:Sponsoring Agency:Sponsoring Agency Representative:DAS/CS Project Manager:DAS/CS Project Number:Project/Action Description:Environmental Consultant Disclosure Statement:(Regulations of Connecticut State Agencies, Section 22a-1a-2)I,,Hereby declare that neither,(Name Of Officer Or Principal Of Firm)(Name Of Corporation Or Firm)nor any of its shareholders, principals or partners, as the case may be, has any financial interest in the outcome of the environmental assessment or the use of the property described above, and will not have such interest at any time during the term of the contract or task letter, which is later.Authorized Signature:(Typed Name)(Signature)(Date)Name Of Firm:Address Of Firm:Copies To:DAS/CS Chief Architect: DAS/CS Project Manager:DAS/CS Project File:End1160 – Environmental Consultant Disclosure Statement ................
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