Form Mde/wma-Per018 - Financial Management Plan - Privately Owned Water/sewerage Systems Page 2
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209.06
PART III - CONTINUE
B-1
Identify items that may require extraordinary repairs beyond normal annual OM&R and estimate costs for these items:
Item
Estimated Cost
________________________________
$ ____________________________
________________________________
$ ____________________________
________________________________
$ ____________________________
________________________________
$ ____________________________
B-2
Identify sources/amount of funds available to cover costs associated with the above listed extraordinary repairs (e.g., line of
credit, bond, escrow account, replacement reserve, working capital etc.)
Fund Source
Amount of Fund
_______________________________
$ ____________________________
_______________________________
$ ____________________________
_______________________________
$ ____________________________
_______________________________
$ ____________________________
I certify that the information provided above is true to the best of my knowledge.
Signature: ________________________________
Date:___________________
Name: _____________________________________
Title:__________________
Address: _________________________________________________________________________________
Telephone: _______________________________
Please return this completed form and attachments to:
Maryland Department of the Environment
1800 Washington Boulevard
Engineering and Capital Projects Program (ECPP)
Office of Budget and Infrastructure Financing
Baltimore, Maryland 21230
Attention:
Janet Hamilton, Permit Coordinator
******************************************************************************
FOR OFFICE USE
_____________ Approved by _______________________
Date: ____________
(Approval)
(signature)
_____________ Disapproved by ____________________
Date: ____________
(Disapproval)
(signature)
Comment:__________________________________________________________________________
_____________________________________________________________________
MDE/WMA-PER018
Page 2 of 2
September 2012
TTY Users 1-800-735-2258
Recycled Paper
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