* DESCRIPTION OF RECORDS REQUESTED: In the space below, please provide a specific description of the records you would like to inspect or have scanned for you. If possible, include the type of record, title of document, dates, permit numbers, name of facility, and address or legal description of the facility location.

* HOW TO OBTAIN REQUESTED RECORDS:
I want to inspect these records on (please list preferred date and time):
I want to pick up an electronic copy of these records on (please specify date and time):
I want to have electronic copies of these records mailed to me at the above address.

FEES:Please note the agency assesses fees for staff time and materials necessary to provide the records, and may also require advance payment. Large scanning jobs may be sent to a commercial copy center at your expense.

PROHIBITED USES: KSA 45-230 prohibits the use of names and addresses contained in public records for certain commercial purposes. By submitting this request, you are signing the following written certification that you will not use the information in the records for any purpose prohibited by law.

Pursuant to KSA 45-220(c), I hereby certify that I do not intend to, and will not: (A) use any list of names or addresses contained in or derived from the records or information for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or (B) sell, give, or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. I understand that selling, giving, or receiving any list of name and addresses contained in or derived from public records is prohibited by KSA 45-230, and that any person who knowingly violates this section may be liable for the payment of a civil penalty not to exceed $500 for each violation.

OPTIONAL AUTHORIZATION:

I authorize the Kansas Department of Health and Environment to fulfill the above request and bill me for any fees, provided the total fee amount does not exceed:

* SELECT ALL THE APPROPRIATE SECTIONS WITHIN BUREAU OF REMEDIATION: In the box below please select all the appropriate sections for handling this request and click the 'Submit' button. Requests not routed or routed to the incorrect sections may be delayed.

Assessment & Restoration Section 
(includes Clandestine Drug Lab, Dry Cleaning, Federal Facility, Landfill, Spill and Superfund Programs)

Remedial Section 
(includes Environmental Use Control, Voluntary Cleanup, State Water Plan, Brownfields, State Cooperative, and Site Assessment Programs)

Storage Tank Section 
(includes Underground Storage Tank, Aboveground Storage Tank, and Essential Fuel Supply Trust Fund Programs)