C. Data Sharing Form for Governmental Entities
Information About the Requester 						Please Print
Governmental Agency: 	______________________________________________
Contact: 	__________________________________________________________
Title: 		__________________________________________________________
Address: 	__________________________________________________________
_____________________________ ____________ ________________
(Municipality) 			(State) 		(Zip Code)
Telephone #: (______) ______ -________ Extension: ________
What information do you want to share?
System Description:	____________________________________________________
______________________________________________________________________
______________________________________________________________________
Source of Information:  _________________________________________________
______________________________________________________________________
______________________________________________________________________
Data Format: __________________________________________________________
Provide File Definitions including All Fields, Field Lengths & Field Types

Submit this form and file definitions to:
NJDEP – Site Remediation & Waste Management Program
Bureau of Field Operations – Case Assignment Section
401 East State Street – 5th Floor
PO Box 028
Trenton, NJ 08625-0028
ATTENTION: SRWM_NJEMS