NR 169.19(2)(a)1.1. The owner or operator’s name and address and a statement indicating how the applicant qualifies as an owner or operator under s. NR 169.07.

NR 169.19(2)(a)2.2. If an agent of the owner or operator is directing the response action, the name, address and phone number of the agent and a dated copy of the agency agreement.

NR 169.19(2)(a)3.3. A statement indicating whether the owner or operator has applied or will apply to another department program or another government agency for reimbursement of response action costs incurred for the same facility.

NR 169.19(2)(a)4.a.a. Names, addresses and phone numbers of all co–owners and all co–operators.

NR 169.19(2)(a)4.b.b. A certification that the owner or operator has made a reasonable effort to notify other owners or operators.

NR 169.19(2)(a)5.5. Dry cleaner facility information including information on whether the facility is still operating or operable, pollution prevention measures implemented and information on the construction of the facility.

NR 169.19(2)(a)7.7. Consultant information, including the contact name and business name.

NR 169.19(2)(a)8.8. Insurance information, including a statement indicating whether any portion of the response action costs for which the owner or operator seeks reimbursement may be covered by insurance, or a statement from the owner’s or operator’s insurance company stating that the insurance company has denied the owner’s or operator’s claim for reimbursement of the response action costs

NR 169.19 NoteNote: Forms are available at no charge from the remediation and redevelopment program in any department regional or central office or by contacting the department at (608) 266-2111.

NR 169.19(2)(b)1.1. The total eligible response action costs for which the owner or operator seeks reimbursement from the department and a breakdown of those costs into the categories listed in par. (e).

NR 169.19(2)(c)(c) A map showing the town, range, section and quarter–quarter section location of the facility.

NR 169.19(2)(d)(d) An accurate legal description of the land parcel where the facility is located which corresponds to the most recent accurate parcel description filed with the register of deeds in the county where the land parcel is located.

NR 169.19(2)(e)(e) A cost detail worksheet form which lists and identifies each eligible response action cost for which the applicant seeks reimbursement from the department, indicates whether the response action cost was for an immediate action, interim remedial action, site investigation or remedial action, and allocates cost to one of the following categories:

NR 169.19 NoteNote: Forms are available at no charge from the remediation and redevelopment program in any department regional or central office or by contacting the department at (608) 266-2111.

NR 169.19 NoteNote: Section 292.65 (8) (j), Stats., provides that if any person applies for reimbursement of an ineligible cost, the department may deduct 50% of the amount of that cost from that person’s eligible reimbursement claim. An owner or operator who is not certain whether a cost is eligible for reimbursement under this chapter may contact the department for a preliminary opinion under s. NR 169.19 (1).

NR 169.19(2)(f)(f) Invoices or other information documenting and cross referencing each of the costs listed under par. (e) and identifying the nature of the materials or services provided, the amount charged for the materials or services, the identity of the provider, and the dates on which the materials or services were provided