B. Data Correction Form for Individuals

Information About the Requester 					Please Print
Name: 	_________________________________________________________
Title:	_________________________________________________________
Affiliation:	_________________________________________________________
Address:	_________________________________________________________
___________________________ 	_______________ 	_________
(Municipality) 			(State) 			(Zip Code)

Telephone #: (______) ______ -________ Extension: ________

Complete the Reverse Side of this Form and Return to:
NJDEP – Site Remediation Program
401 East State Street
PO Box 028
Trenton, NJ 08625-0028

ATTENTION: Data Supplement/Correction
For* _____________________________

* Specify Contact Designated in Known Contaminated Sites in New Jersey
Completed Forms may also be faxed to (609) 633-1454
Make Copies and Attach Additional Sheets as Necessary

Use this form to provide supplemental information or data corrections for:
Site Name: 		___________________________________________________
Preferred ID: 	___________________________________________________
Contact:  ________________________________
Is this a: Correction __ or Additional Information __
Specify the Change Requested:
Site Name: 		___________________________________________________
Site Address:		___________________________________________________
Municipality:		_____________________ County: ______________________
Block/Lot Information: (List each block and lot separately e.g. Block 1, Lot 1;
Block 1, Lot 2; Block 1, Lot 3; Block 2, Lot 1)
_____________________________________________________________________
X-Coordinate (Easting): __________  & Y-Coordinate (Northing): __________
Source:__ Global Positioning System (GPS)
__  NJDEP iMap
__ Other—Please Specify:______________________________
Other Names (AKAs): __________________________________________________
______________________________________________________________________
Other: ________________________________________________________________
______________________________________________________________________
Source of Information: __________________________________________________
(e.g.Tax Map, Municipal Records, etc.)
Is documentation attached? __ Yes or __ No  (To expedite the processing of your request, please include documentation)