* DESCRIPTION OF RECORDS REQUESTED: In the space below, please provide a specific description of the records you would like to inspect or have copied 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. Attach additional pages, if necessary.

* HOW TO OBTAIN REQUESTED RECORDS:
I want to inspect these records on (please list preferred date and time):
I want to pick up copies of these records on (please specify date and time):
I want to have paper copies of these records mailed to me at the above address.
I want to have an electronic copy of these records emailed to me (file size less than 3 MB), or mailed to me by CD-ROM (file size greater than 3 MB) if these records are available electronically.

FEES: Fees of 25 cents per page for letter and legal-size copies and 50 cents per page for ledger-size copies will be assessed for black and white copies of records provided pursuant to this request. Please note the agency may assess a fee for staff time (clerical and/or technical) necessary to provide the records if your request requires the agency to conduct a records search. The agency may also require advance payment of fees for copying records. Large copying jobs may be sent to a commercial copy center, which will contact you to make billing and shipping arrangements prior to making the copies.

PROHIBITED USES: KSA 45-230 prohibits the use of names and addresses contained in public records for certain commercial purposes. If the records you have requested contain lists of names or addresses, you will be asked to sign a written certification that you will not use the information in the records for any purpose prohibited by law.

OPTIONAL AUTHORIZATION: In order to expedite your request, you may wish to complete the following authorization specifying a maximum fee amount you are willing to pay for requested copies.

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 APPROPRIATE SECTION WITHIN BUREAU OF REMEDIATION: In the box below please select the appropriate section for handling this request and click the 'Submit' button. Requests routed to the wrong section may be delayed.

Note - At least one section below is required for submittal and only one section can receive a request at a time. To submit a request to an additional section, simply close the "Thank You" window that will open upon submittal and uncheck the previous section and choose an additional section and select the 'Submit' buton. The information above will not need to be filled in a second time.