"Contact Information / Notification Registration" - Massachusetts

Contact Information / Notification Registration is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on October 1, 2015;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

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Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
Contact Information / Notification Registration
A. Purpose
Use this form if you need to update your contact information with the MassDEP Drinking Water Program (DWP). You may also
use this form if you are interested in subscribing, or unsubscribing, to DWP email and autodialer notifications, as well as any of
our electronic newsletters.
B. Contact Information
(Required)
I am a (select one):
B1)
Certified Operator
B2)
PWS Owner/Legally Responsible Party
B3)
Board of Health Agent
B4)
Other Interested Party
Mailing Address Line 2
Mailing Address Line 1
State
Zip
City/Town
Provide the corresponding information for the selection made above.
B1. Certified Operator Information
(All Fields Required)
Operator License #
Operator Phone #
Operator Email Address
Operator’s Full Name
B2. PWS Owner / Legally Responsible Party (LRP) Information
(All Fields Required)
Owner / LRP Phone #
Owner / LRP Email Address
Owner’s Full Name / LRP Name
PWS ID #
PWS Name
PWS Mailing Address Line 1
PWS Mailing Address Line 2
PWS Mailing City/Town
PWS Mailing State
PWS Mailing Zip
PWS Phone #
PWS Fax #
PWS Email Address
B3. Board of Health Agent Information
(All Fields Required)
Agent Phone #
Agent Email Address
Agent Full Name
Board of Health Name / Town Name
B4. Other Interested Party
(All Fields Required)
Interested Party Phone #
Interested Party Email Address
Interested Party Full Name
C. Notifications / Publications
(Optional)
I would like to (select one):
Subscribe
Unsubscribe
Select the notifications & publications you would like to subscribe/unsubscribe to:
C1. Email Notifications & Publications
In The Main Newsletter
Well Drillers Newsletter
C2. AutoDialer Notifications
Emergency Notifications
Sampling & Monitoring Reminders
For AutoDialer notifications please provide the phone # where messages should be
delivered.
Phone #
If you would like to receive text message notifications, provide your mobile phone # and
wireless carrier (e.g. Verizon Wireless, AT&T, etc.). Note: Msg, & data rates may apply.
Mobile Phone #
Wireless Carrier
Return Completed
By Email:
program.director-dwp@state.ma.us
(subject: Contact/Registration Update)
th
Form To:
By Mail: MassDEP Drinking Water Program; Attn: Contact/Registration Update; 1 Winter Street, 5
Floor; Boston, MA 02108
frmCntctReg.pdf • rev. 10/2015
Contact Information / Notification Registration• Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection – Drinking Water Program
Contact Information / Notification Registration
A. Purpose
Use this form if you need to update your contact information with the MassDEP Drinking Water Program (DWP). You may also
use this form if you are interested in subscribing, or unsubscribing, to DWP email and autodialer notifications, as well as any of
our electronic newsletters.
B. Contact Information
(Required)
I am a (select one):
B1)
Certified Operator
B2)
PWS Owner/Legally Responsible Party
B3)
Board of Health Agent
B4)
Other Interested Party
Mailing Address Line 2
Mailing Address Line 1
State
Zip
City/Town
Provide the corresponding information for the selection made above.
B1. Certified Operator Information
(All Fields Required)
Operator License #
Operator Phone #
Operator Email Address
Operator’s Full Name
B2. PWS Owner / Legally Responsible Party (LRP) Information
(All Fields Required)
Owner / LRP Phone #
Owner / LRP Email Address
Owner’s Full Name / LRP Name
PWS ID #
PWS Name
PWS Mailing Address Line 1
PWS Mailing Address Line 2
PWS Mailing City/Town
PWS Mailing State
PWS Mailing Zip
PWS Phone #
PWS Fax #
PWS Email Address
B3. Board of Health Agent Information
(All Fields Required)
Agent Phone #
Agent Email Address
Agent Full Name
Board of Health Name / Town Name
B4. Other Interested Party
(All Fields Required)
Interested Party Phone #
Interested Party Email Address
Interested Party Full Name
C. Notifications / Publications
(Optional)
I would like to (select one):
Subscribe
Unsubscribe
Select the notifications & publications you would like to subscribe/unsubscribe to:
C1. Email Notifications & Publications
In The Main Newsletter
Well Drillers Newsletter
C2. AutoDialer Notifications
Emergency Notifications
Sampling & Monitoring Reminders
For AutoDialer notifications please provide the phone # where messages should be
delivered.
Phone #
If you would like to receive text message notifications, provide your mobile phone # and
wireless carrier (e.g. Verizon Wireless, AT&T, etc.). Note: Msg, & data rates may apply.
Mobile Phone #
Wireless Carrier
Return Completed
By Email:
program.director-dwp@state.ma.us
(subject: Contact/Registration Update)
th
Form To:
By Mail: MassDEP Drinking Water Program; Attn: Contact/Registration Update; 1 Winter Street, 5
Floor; Boston, MA 02108
frmCntctReg.pdf • rev. 10/2015
Contact Information / Notification Registration• Page 1 of 1