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Florida Department of Environmental Protection Bob Martinez Center 2600 Blair Stone Road Tallahassee, FL 32399-2400 Charlie Crist, Governor Jeff Kottkamp, Lt. Governor Michael W. Sole, Secretary |
INSTRUCTIONS: Complete the form, print it, sign it and return it to: DEP, Solid Waste Section Mail Station # 4565, 2600 Blair Stone Rd, Tallahassee, Florida 32399-2400.
Small County Consolidated Solid Waste Grant Quarterly/Monthly Reimbursement Request
| 1. Grantee: | 2. Grant: | 3. Payment Req#: |
| 4. Expenditures | 5. Cumulative | |
| In this row, enter dates "FROM" ► | ||
| In this row, enter dates "TO" ► | ||
| 6. Purchase or Repair of Solid Waste Weight Scales | $ | $ |
| 7. Solid Waste Management Program Operating Costs | $ | $ |
| 8. Planning Costs | $ | $ |
| 9. Construction & Maintenance of Solid Waste Facilities | $ | $ |
| 10. Solid Waste Management Education for Employees or Public | $ | $ |
| 11. Recycling Demonstration Projects | $ | $ |
| 12. Waste Tire Program Cost | $ | $ |
| 13. Litter Control & Prevention Projects | $ | $ |
| 14. Total Expenditures | $ | $ |
| 15. Grant Award | $ | |
| 16. Prior Reimbursements | $ | |
| 17. This Payment Request | $ | |
| 18. Total State Payments | $ | |
| 19. Balance of Award | $ |
In requesting this payment the undersigned represents that
he / she is duly authorized to act on behalf of the recipient.
he / she is duly authorized to act on behalf of the recipient.
_________________________________________ Signature of Authorized Representative |
_________________________________________ Title |
_________________________________________ Date |