audit - submittal form

New Compliance and EnforcementJerseyDepartment ofEnvironmental SELF-DISCLOSURE REPORTProtectionInstructionsPursuant to Departmental policy as well as proposed new rules at N.J.A.C. 7:33-1 et seq.which appeared in the New Jersey Register on August 18, 2003, a regulated entity maybe eligible for a 75 to 100 percent penalty reduction for violations that it discovers,discloses and corrects.In order to self-disclose a violation, complete this form and send to:New Jersey Department of Environmental ProtectionCompliance and EnforcementPO Box 422th401 East State Street, 4 floorTrenton, NJ 08625-0422Attn: Self-DisclosuresYou should also e-mail a copy of this form to Peg.Hanna@dep.state.nj.us and keep acopy for your own files. Attach additional pages as necessary. If you have questions,please call (609) 633-2306.New Compliance and EnforcementJerseyDepartment ofEnvironmental SELF-DISCLOSURE REPORTProtection1. Name, Address and Location of FacilityEnter the name, mailing address, e-mail address (if any), phone number and location of the facilityfor which the regulated entity is submitting this Self-Disclosure Report.Facility Name: __________________________________________________________________Mailing Address: ________________________________________________________________e-mail Address (optional): _________________________________________________________Phone No.: ...