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Form 26r Dep 2011-2023
Needs to match the date noted below.
DEP USE ONLY
Date Received & General Notes
General Reference 287.54
Date Prepared/Revised
SECTION A. CLIENT (GENERATOR OF THE WASTE) INFORMATION
Company Name
If a Subsidiary, Name of Parent Company
EPA Generator ID#
Company Mailing Address Line 1
Company Mailing Address Line 2
Company Address Last Line – City
Company Contact Last Name
State
First Name
Phone
MI
Municipality
Contact Phone
Zip+4
Ext
Suffix
County
Ext
Contact Email Address
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