HWR-001
3/95 State of New Jersey
Department of Environmental Protection |
"Request to Deactivate EPA ID Number"
EPA ID No. __________________________________
Company Name: ______________________________________________________
Site Address: _____________________________
_______________________
(street)
(city / town)
_____________ ___________ ___________
____________
(state)
(zip code)
(lot)
(block)
Mailing Address: _____________________________________________________
(street / P.O. box)
(city / town)
______________________
_________________________
(state)
(zip
code)
Company Contact: ____________________ _____________________
(name)
(area code and phone
number)
Reasons for deactivating EPA ID No. (Check all appropriate boxes.)
| o | The EPA ID number was obtained for a one time cleanup which is completed. |
| o | The site has completed an ECRA cleanup (indicate ECRA Case # ) |
| o | Other |
Is the site presently occupied? (circle yes or no )
Sign and date the application below, and retain the last page (pink copy)
for your records.
______________________________ ____________________________
(printed name)
(signature)
___________________________________ __________________________
(title)
(date)
Submission of false information is a violation of N.J.A.C. 7:26-5.6 and N.J.A.C.
7:26-7.3.
copies: NJDEP/DSHW Manifest section (address above)
Applicant is to keep a copy