INSURER, LENDER OR TRUSTEE LETTERHEAD
(Including Address/Telephone Information)

								Date

Attn:  Remediation Funding Source Coordinator
New Jersey Department of Environmental Protection
Site Remediation and Waste Management Program
Remediation Funding Source Unit
Mail Code 401-06X
P.O. Box 420
401 East State Street
Trenton, NJ  08625-0420

RE:	NJDEP Program Interest #
	ISRA CASE # if applicable
	Site Name/Location

	Annual Renewal Verification
	[Line of Credit or Environmental Insurance Policy or Trust Account or Surety Bond] #

To Whom It May Concern:

	In accordance with N.J.A.C. 7:26C-5 et seq., please accept this notification that the [Line of Credit, Environmental Insurance Policy, Remediation Trust Fund Agreement, or Surety Bond], dated ______________________, between________________________, and _____________________, remains in effect and will continue to be in effect for the next 12- month period.

	The current value of the [Environmental Insurance Policy, Line of Credit, Remediation Trust Fund, or Surety Bond] is $____________.

						Signature:_______________________

						Name: _________________________

Title___________________________

(Attachment: Trust Bank Statement if available)