Notification Of Exempt Recycling Activities Form - New Jersey Department Of Environmental Protection
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2N O T I F I C A T I O N O F E X E M P T R E C Y C L I N G A C T I V I T I E S
NAME: __________________________________________ TITLE: __________________________________
CORPORATION / COMPANY: _________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________
MUNICIPALITY: _______________________________________ STATE: __________ ZIP: ______________
TELEPHONE NUMBER: (________) __________________ FAX NUMBER: (________) __________________
area code
area code
_________________________________________________________________________________________________________________
WHICH EXEMPTION FOUND AT N.J.A.C. 7:26A-1.4(a) WILL YOU BE OPERATING PURSUANT TO?*
__________
(see back of form and enter the exemption number)
_________________________________________________________________________________________________________________
LOCATION WHERE ACTIVITY IS TO BE CONDUCTED: (i
f activity is to be conducted at more than one location, you must
complete and submit a notification form for each location.)
MUNICIPALITY:__________________________________ COUNTY: __________________________________
STREET ADDRESS
BLOCK # :_________ / LOT # :__________
:_______________________________________________
LOCATION DESCRIPTION:
(construction or demolition site, shopping mall, farm, industrial park, etc.) _________________________
_________________________________________________________________________________________________________________
DATE ACTIVITY WILL COMMENCE:
________/_________/__________
Month
Day
Year
ANTICIPATED COMPLETION DATE:
________/_________/__________
(if applicable)
Month
Day
Year
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document
and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I
believe that the information is true, accurate, and complete. I further certify that the operation described herein satisfies the
criteria for exemption as set forth in N.J.A.C. 7:26A-1.4. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment. I understand that, in addition to criminal penalties, I may be
liable for a civil penalty pursuant to N.J.A.C. 7:26-5 and that submitting false information may be grounds for termination of any
exemption.
Name
Title
(print) ________________________________________
(print) ______________________________________________
Signature
Date
: ________/_________/__________
__________________________________________
Month
Day
Year
* An unofficial copy of the Recycling Regulations, N.J.A.C. 7:26A-1.4, can be obtained from the Department's internet
website at: /dep /dshw / resource / rules.htm
Please complete and mail this form to your host municipality and host county health department and solid waste
coordinator. Please then mail the completed form along with proof of mailing to your host municipality and county
to: New Jersey Department of Environmental Protection, Division of Solid and Hazardous Waste, Bureau of Recycling
& Planning, P.O. Box 414, Trenton, New Jersey 08625-0414.
Received by NJDEP Solid & Hazardous Waste Management Program
(This section to be completed by NJDEP)
Signature
Date
: ________/_________/__________
__________________________________________
Month
Day
Year
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