General Statutes and any other applicable law.” Signature of permittee or duly authorized representative of permittee: _____________________________________ Date: Printed name: Title: Signature of person responsible for preparing report: ______________________________________ Date: Printed name: Title: Phone #: Fax #: E-mail Address: Completed forms can be submitted to the CT Department of Energy& Environmental Protection by any of the following ONE methods: Fax (860) 424-4059 Attn: Solid Waste Facility Reporting; Or Scanned & E-Mailed To (Do not send hard copy if sending electronically); Or Land-Mailed (CT DEEP; Bureau of MM&CA Recycling Office; 79 Elm Street - 4th Floor; -Hartford, CT 06106-5127; – Attn: Solid Waste Facility Reporting ) Must be double-sided and preferably on paper with a minimum 30% post-consumer content. PLEASE CONSERVE PAPER - Do not fax or submit pages or sections that you intentionally left blank. Contact (860 424-3334) to confirm receipt of report by DEEP
General Statutes and any other applicable law.” Signature of permittee or duly authorized representative of permittee: _____________________________________ Date: Printed name: Title: Signature of person responsible for preparing report: ______________________________________ Date: Printed name: Title: Phone #: Fax #: E-mail Address: Completed forms can be submitted to the CT Department of Energy& Environmental Protection by any ONE of the following methods: Fax (860) 424-4059 Attn: Solid Waste Facility Reporting; Or Scanned & E-Mailed To (Do not send hard copy if sending electronically); Or Land-Mailed (CT DEEP; Bureau of MM&CA – Recycling Office; 79 Elm Street - 4th Floor; -Hartford, CT 06106-5127; Attn: Solid Waste Facility Reporting ) Must be double-sided and preferably on paper with a minimum 30% post-consumer content. PLEASE CONSERVE PAPER - Do not fax or submit pages or sections that you intentionally left blank. Contact (860 424-3334) to confirm receipt of report by DEEP
CommercialGP_Appendix_E_Fillable_Form_NonRCRA_HW.docx