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4 <br /> SAMPLE F <br /> North Carolina Department of Commerce <br /> Request for Release of Funds and Certification <br /> Environmental <br /> 1. Recipient's Name 2. Grant Agreement Number <br /> Orange County 95-0-0138 <br /> 3. Project Number <br /> 4. Recipient's Address (include Street, City, 5. Date of Request/ Certification <br /> State, and Zip Code <br /> 200 S. Cameron Street December 29, 1995 <br /> Hillsborough, N.C. 27278 <br /> 6. REQUEST FOR RELEASE OF FUNDS. Release of approved grant-funds for the <br /> following project is requested: <br /> PROJECT <br /> Orange County Scattered Site Housing Rehabilitation Program. <br /> 7. CERTIFICATION: With reference to the above project, the undersigned <br /> officer of the recipient hereby certifies: <br /> That the recipient has fully carried out its responsibilities for environmental <br /> review, decision-making, notice, publication, and action pertaining to the <br /> project named above; that the recipient has complied with the National <br /> Environmental Policy Act of 1969; that the recipient has with the <br /> environmental procedures, permit requirements and the statutory obligations <br /> under such laws cited in 24 CFR Part 58.5; that the recipient has taken into <br /> account the environmental criteria, standards, permit requirements and other <br /> 842 <br />