NJDEP - Community Right To Know Reporting Exemption Form

Community Right To Know Reporting Exemption Form

Please Complete this Form if you are Claiming an Exemption from CRTK Reporting Requirements
Pursuant to the CRTK Regulations NJAC 7:1G-3.2 (f), (g) or (h)

*Facility Name:

*Facility Mailing Address: Street Address, City, Zip

City State: Zip

*Physical Address: Street Address, City, Zip

City State: Zip

*Current Business Activities

*11 Digit CRTK Facility Identification Number:

*9 Digit FEIN (Federal Employer Identification Number):

*Please Select the Exemption that Applies to your Facility by clicking in the box:

Administrative Office Only (In order to qualify for this Exemption ALL Entities Under the FEIN Listed Above must be Engaged in Administrative Office Activities Only)

Unstaffed Site (see definition of Unstaffed Site at NJAC 7:1G1.2 (h)

Non User of Environmental Hazardous Substances (see Environmental Hazardous Substance List)

User Below Threshold of Environmental Hazardous Substances (see Environmental Hazardous Substance List)

*Company Contact Name:

Phone Number:

* Contact Email Address:

*Signature:

Submittal of this form shall constitute certification that the information contained herein is true, accurate and complete.

You MUST keep a signed copy of this form at your location.

THE NJDEP WILL BE CONDUCTING RANDOM INSPECTIONS TO VERIFY THE ACCURACY OF THESE SUBMITTALS

* Required Fields