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F the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 PA. C.S. Section 4904 b ). Print Name of Responsible Person Signature Title Date Contact DEP Via phone: 717-783-9258 Or Sent To: USPS Mail PA Department of Environmental Protection Bureau of Waste Management Division of Reporting and Fee Collection Rachel Carson State Office Building P.O. Box 8550 Harrisburg, PA 17105-8472 Courier PA Department of Environmental Protection Bureau of Waste Management Div.

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