Connecticut Hazardous Waste Manifest Database Order Form

							                    STATE OF CONNECTICUT
                    DEPARTMENT OF ENVIRONMENTAL PROTECTION
                    BUREAU OF MATERIALS MANAGEMENT & COMPLIANCE ASSURANCE
                    WASTE ENGINEERING & ENFORCEMENT DIVISION



     Connecticut Hazardous Waste Manifest Database Order Form

The database is in Microsoft Access format.                                                  DEP USE ONLY
You must have Microsoft Access, version 2000 or newer,                          Check No.:
on your PC to use this data.
                                                                                Date:

                                                                                Amount Paid:

Part I: Purchaser Information

 Name:
 Mailing Address:
 Note: We ship via UPS (United Parcel Service). UPS does not deliver to PO Boxes.
 City/Town:                                                          State:   Zip Code:
 E-Mail Address:
 Telephone Number:                                                   ext.     Fax:



Part II: Database Information

 Available years: 1984 through 2007
 Cost: $50 for a single year. For each additional year, please add $6.25 per additional year.
 Shipping is included in the price.
     Please indicate years desired:           Complete database (1984 - 2007) Cost = $187.50

                                              Other - please list years:



Part III: Quantity of Database CD's

     Number of CD's ordered:

     Amount enclosed:



Please return this form along with your check payable to the Department of Environmental Protection to:
         Hazardous Waste Manifest Program
         Department of Environmental Protection
         79 Elm Street
         Hartford, CT 06106-5127
         860-424-3375

Bureau of Materials Management & Compliance Assurance
DEP-WEED-ORDER-001                                          1 of 1                                     Rev. 06/11/09