Site Name: ________________________

___________________________________

EPA ID No __ __ __ __ __ __ __ __ __ __ __ __

OFFICIAL USE ONLY
Fee Received_____________
RA _____________________
Date Received __________
Received By ____________

FEE VERIFICATION FORM
INSTRUCTIONS: If you are required to complete a report, complete the two fields above, the fee category information below and attach the check where indicated. If you are required to complete a report, return this form with your report. When submitting multiple reports, each site will require a separate Fee Verification Form; however, any fees owed may be combined into one check. If a report is not due from your company, do not return this form.
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Attach check here - DO NOT SEND CASH.

Make check payable to:
Mail report with check to:

Treasurer, State of New Jersey
New Jersey Department of Treasury
Division of Revenue
P.O. Box 417
Trenton NJ 08646-0417

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No fee is due if this site was not a RCRA large quantity generator (LQG).
(Refer to the second page of the instruction booklet for the definition of a RCRA LQG)