Bergen County Clean Communities Summary Report

Name of Organization(Required)

Mailing Address(Required)

Contact Person(Required)

Phone(Required)

Email(Required)

Location Of Project Site(Required)

Municipality of Project Site(Required)

Project Site GPS Coordinates(Required)

Clean Up Date(Required)

Number of Participants(Required)

Hours Worked by Group(Required)

Miles(Required)

Size of Project Site (this figure can be estimated. If this information is not provided your group is not eligible for funding)

Acres(Required)

Use “Miles” for highway/roadside clean ups and “Acres” for other areas.

Clean Up Project Description(Required)

Please provide a brief description of the clean up project. Feel free to include any comments about the Clean Communities Program.

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Director/Health Officer

One Bergen County Plaza • 4th Floor • Hackensack, NJ 07601-7076
Phone: 201-634-2600 • Fax: 201-336-6086
Health & Safety Hotline: 201-225-7000

Departments & Services