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Hazardous Waste Manifest Order Form


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79 Elm Street • Hartford, CT 06106-5127 www.ct.gov/deep Affirmative Action/Equal Opportunity Employer

Hazardous Waste Manifest

Order Form




1. Requestor Information

Name:      

Mailing Address:      

City/Town:       State:    Zip Code:      

Business Phone:       ext.      

Contact Person:       Title:      

Email:      


DEEP USE ONLY

Date Rec’d: _______________

Box #: ______________

Location: ______________

Accession Year: ______________

Accession #: ______________

Date Box Requested: ______________

Date Box Received: _______________

Date Closed: ________________


2. Manifest Information

Manifest Number:      

Date Shipped:      

Batch Number (if known):     


3. Generator Information

EPA ID #:      

Site Address:      

City/Town:      



Note: The DEEP has sufficient space to keep only the most recent five (5) years of manifests on-site. Please allow sufficient time for us to produce earlier manifests.
Email this form to: deep.manifests@ct.gov


One request per form

DEP-WEED-APP-001 Page of Rev. 5/22/2014




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