LSRP Notification of Retention or Dismissal Instructions Page 2 of 3
Version 3.0 05/07/12
Section D. Licensed Site Remediation Professional Information and Statement
Complete this section to provide contact and license information concerning the LSRP. The LSRP that has been
retained/released must sign and date the certification.
LSRP ID Number: The LSRP License Number
First and Last Name: Name of the LSRP
Phone and Fax Number: The phone and Fax number for the LSRP
Mailing Address: The business address for the LSRP
Email Address: The email address for the LSRP
The certification, if applicable, shall be signed and dated by the LSRP
The Licensed Site Remediation Professional should note by placing an “X” in the box if there have been no changes in
this section since the last submittal.
Section E. Person Responsible for Conducting the Remediation Information and Certification
The certification in this section shall be signed and dated by the person responsible for conducting the remediation. The
certification in this section shall not be signed by the licensed site remediation professional or law firm hired to assist the
owner or operator with their compliance obligations. The certification required in this section shall be executed as follows:
1. For a corporation or limited liability company, by a principal executive officer of at least the level of vice president; or
2. For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
3. For a municipality, state, Federal or other public agency, by either a principal executive officer or ranking elected
official; or
4. By a duly authorized representative of the corporation, partnership, sole proprietorship, municipality, state or Federal
or other public agency, as applicable. A person is deemed to be a duly authorized representative if the person is
authorized in writing by an individual described in 1, 2 or 3 above and the authorization meets the following criteria:
i. The authorization specifies either an individual or a position having responsibility for the overall operation of the
industrial establishment or activity, such as the position of plant manager, or a superintendent or person of
equivalent responsibility (a duly authorized representative may thus be either a named individual or any individual
occupying a named position);
ii. The written authorization is submitted to the NJDEP along with the certification; and
iii. If an authorization is no longer accurate because a different individual or position has responsibility for the overall
operation of the industrial establishment or activity, a new authorization satisfying the requirements of this section
shall be submitted to the NJDEP prior to or together with any reports, information, or applications to be signed by
an authorized representative.
Provide the full legal name of the person responsible for conducting the remediation i.e., ABC Corporation;
Provide the full name of the representative of the person responsible for conducting the remediation, pursuant to
N.J.A.C. 7:26C-1;
Provide the title of the representative of the person responsible for conducting the remediation;
Provide the telephone number, extension number, and fax number of the representative of the person responsible for
conducting the remediation;
Provide the mailing address, including the city/town, state, and zip code of the representative of the person responsible
for conducting the remediation;
Provide the email address of the representative of the person responsible for conducting the remediation;
1. Indicate if you do not yet own the property and are conducting remediation to meet due diligence requirements.
2. Indicate if the scope of remediation is only to address one or more unregulated heating oil tanks at the site.
3. If you maintain that you meet one of the statutory criteria that establish a defense to Spill Act liability indicate the
appropriate category. Note that checking this box does not imply that the NJDEP is in agreement with the indicated
defense. If such defense does not exist, regardless of how this form is completed, the affirmative obligation to
complete remediation in compliance with applicable timeframes applies.
4. Indicate if you are conducting remediation in order to meet licensing requirements for a child care facility. If you
answer “Yes,” indicate whether you are a tenant or the property owner.