Division of Solid and Hazardous Waste Solid & Hazardous Waste Regulation Element 401 East State Street P.O. Box 422 Trenton, NJ 08625-0422 Tel. .# 609-292-7081

Bureau of Hazardous Waste Regulation Conditionally Exempt Small Quantity Generator NJX PROGRAM APPLICATION FORM

Please complete all of the following information. An incomplete application will not be processed.

Company Name _________________________________________________________________

Street Address __________________________________________________________________

Street City _______________________________________ Zip Code ______________________

Mailing Address _________________________________________________________________
                                     (if different from above)

Mail City _______________________________________________Mail State ________________

Zip Code ____________________ County ____________________ SIC Code _____________

Contact Name ___________________________________________________________________

Title ___________________________________________________________________________

Phone Number _________________________________________________ (including area code)

Emergency Phone Number ________________________________________ (including area code)

Please check the category that applies to your operation.

In a calendar month Generation Limits do not exceed:

_____ 100 kilograms of non-acutely hazardous wastes.

_____ 1 kilogram of acutely hazardous wastes.

_____ 100 kilograms of any residue or contamination soil, waste, or other debris resulting from the
cleanup of a spill of acute hazardous waste.

List any previous EPA ID. numbers below (if applicable):

_______________________________________________________________________________

_______________________________________________________________________________

I certify that I have personally examined and am familiar with the information submitted in this application and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate and complete and that the applicant meets the eligibility requirements of the Conditionally Exempt Small Quantity Generator NJX Number Program.

New Jersey is an Equal Opportunity Employer