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Cerfa 12571 PDF Remplissable Form
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NOM :
Adresse :
Tél. :
Mél :
Personne à contacter :
3. Dénomination du déchet
Rubrique déchet :
2. Installation de destination ou d’entreposage ou de
reconditionnement prévue
Entreposage provisoire ou reconditionnement
oui (cadres 13 à 19 à remplir)
non
N° SIRET : |_|_|_| |_|_|_| |_|_|_| |_|_|_|_| |_|
NOM :
Adresse :
Tél. :
Mél :
Personne à contacter :
Fax :
Fax :
N° de CAP (le cas échéant) :
Opération d’élimination / valorisation prévue (code D/R) :
Consistance...
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