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SECTION C— BUDGET FUNDING SOURCE <br /> ESTIMATED TOTAL COST OF PROJECT <br /> Contribution from other PLP's $0.00 <br /> Contribution from other sources $0.00 <br /> Remaining Eligible Cost $ <br /> REQUESTED GRANT OR LOAN AMOUNT $3,775,332.00 <br /> POSSIBLE FUTURE CONTRIBUTIONS/SETTLEMENTS $0.00 <br /> Financial/Legal Contact regarding Contributions/Settlements <br /> Name <br /> Title <br /> Address <br /> Telephone <br /> Fax <br /> Email <br /> Do you have any existing insurance policy(ies)for post release discovery to cover unanticipated cleanup costs? <br /> Yes J No ❑ note: only if outside of CAP requirements. <br /> MATCHING FUNDS BY SOURCE <br /> Cash Yes Split to be determined <br /> General Obligation Bonds Yes <br /> Insurance Settlements 0 <br /> Local Improvement District (LID) 0 <br /> Revenue Bonds 0 <br /> Non-Ecology Grants (Identify) 0 <br /> Other 0 <br /> TOTAL MATCHING FUNDS 0 <br /> ��III„ CERTIFIC%ATVN-ANDiAGKEMEN,WM NVW; % `-� <br /> The undersigned representative certifies that the information submitted herewith is true and correct to the best of his/her <br /> knowledge and belief, and is authorized to sign and submit this application. <br /> The applicant agrees that if a grant is awarded on the basis of this application or any revision or amendment thereof, it will <br /> comply with all applicable statutory provisions and with the applicable terms,conditions, and procedures of the Department of <br /> Ecology grant regulation and of the grant agreement. <br /> Signature of Authorized Representative Typed Name and Title <br /> Date Telephone No. (include area code) <br /> ECY 070-104 <br />