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Known Contaminated Sites in NJ Feedback Data Corrections Forms - Governmental Entities


Data Sharing / Correction Form for Governmental Entities

Note: If you need to send us copies of supporting documentation (e.g.Tax Map, Municipal Records, etc.), download and use the alternate versions of the form. Once completed mail or fax the form and attachments to the address on the form.

Alternate Formats:
Adobe Acrobat [pdf 74 Kb] | MS Word [doc 20 Kb] | Rich Text Format [rtf 5 Kb] | Help for File Formats

Fields with an * are required to be completed. The others are optional.

Your Contact Information:

* Governmental Agency:
* Your Name:
* Address Line 1:
  Address Line 2:
* Municipality
* State:
* Zip Code:
* Telephone Number (including Area Code): Extension:
  Internet Email Address:

Supplemental Information or Data Corrections:

* Contact Designated in KCS-NJ Report Entry for the Site:
(If you're not sure, select "Not sure". More info on the Bureaus)
* Site Name:
* Preferred ID
  Case Number:
* Is This a Correction
or Additional Information ?

Specify the Correction Requested:

  Corrected Site Name:
  Corrected Site Address:
  Corrected Site Municipality:
  Corrected Site County:
  Corrected Status:
(Definitions for Status)
  Corrected X Coordinate (Easting):
  Corrected Y Coordinate (Northing):
  Corrected Coordinate Source: Global Positioning System (GPS)
Other -- Please specify:

Specify the Additional Information:

  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)
  Other Names (AKAs):
  Other Information:
  Source of Information:
(e.g.Tax Map, Municipal Records, etc.)

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