TOWN OF
BOARD OF HEALTH
2008 APPLICATION
$150.00 Fee (per truck) $200 new truck or late fee
per truck
PERMIT NUMBER: ___________
Application for permit to remove and/or transport offensive substances within the Town of
Pursuant
to the provisions of Massachusetts General Laws, Chapter 111, Sections 31, and
The State Environmental Code, Title V:
Minimum Requirements for the Subsurface Disposal of Sanitary Sewerage.
(Please Print or Type -
illegible or incomplete applications will be rejected.)
BUSINESS
NAME:
______________________________________________________
BUSINESS
ADDRESS:
___________________________________________________
CITY:
________________________________STATE___________ZIP: ___________
NAME
OF APPLICANT:
_________________________________________________
POSITION:
____________________________________________________________
TELEPHONE:
( )_____________________________________________________
EMAIL
ADDRESS:____________________________________
DESCRIPTION
OF VEHICLE:
Make:
__________________ Year: _____________________
Type:
___________________ Capacity: __________________
Color:
___________________ Plate
No.: __________________
I am familiar with and will abide by the
Rules and Regulations for refuse collection as set forth by the
Failure to abide by the Rules and
Regulations will result in REVOCATION.
________________________________________________________ ____________________
Signature
of applicant Date
APPROVED BY:
_________________________ Date:
_________________
Rejected: ______________________________ Date _________________