"Application for Industrial Wastewater Hauler Permit" - Massachusetts

Application for Industrial Wastewater Hauler Permit is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on June 1, 2017;
  • 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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Download "Application for Industrial Wastewater Hauler Permit" - Massachusetts

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Commonwealth of Massachusetts
$
City/Town of
Fee
Application for Industrial Wastewater Hauler
Permit
Expires (close of year issued)
MassDEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
In accordance with MGL c. 111, Section 31A, and 314 CMR 18.12, the undersigned makes
application to the Board of Health or approving authority for permission to remove and transport
Important: When
industrial wastewater and the content of industrial wastewater holding tanks as set forth below:
filling out forms
on the computer,
use only the tab
Applicant Information:
key to move your
cursor - do not
use the return
Name
key.
Company Name
Address
City/Town
State
Zip Code
Telephone Number
Number and Types of Equipment and their gallon capacity:
Number
Type
Gallonage
Number
Type
Gallonage
Number
Type
Gallonage
Areas from which industrial wastewater will be accepted (append customer list):
List all locations where septage will be disposed of (include a copy of the contract or the approval for
use of the disposal location):
Certification
I certify that the information I have provided above is true and accurate. I recognize that it is a
violation of this permit to dispose of industrial wastewater anywhere other than the identified disposal
locations or others approved by the Board in writing as an amendment to this permit.
Signature of Applicant
Date
iwhaulerapp.doc • 06/17
Application for Septage Hauler Permit • Page 1 of 1
Commonwealth of Massachusetts
$
City/Town of
Fee
Application for Industrial Wastewater Hauler
Permit
Expires (close of year issued)
MassDEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
In accordance with MGL c. 111, Section 31A, and 314 CMR 18.12, the undersigned makes
application to the Board of Health or approving authority for permission to remove and transport
Important: When
industrial wastewater and the content of industrial wastewater holding tanks as set forth below:
filling out forms
on the computer,
use only the tab
Applicant Information:
key to move your
cursor - do not
use the return
Name
key.
Company Name
Address
City/Town
State
Zip Code
Telephone Number
Number and Types of Equipment and their gallon capacity:
Number
Type
Gallonage
Number
Type
Gallonage
Number
Type
Gallonage
Areas from which industrial wastewater will be accepted (append customer list):
List all locations where septage will be disposed of (include a copy of the contract or the approval for
use of the disposal location):
Certification
I certify that the information I have provided above is true and accurate. I recognize that it is a
violation of this permit to dispose of industrial wastewater anywhere other than the identified disposal
locations or others approved by the Board in writing as an amendment to this permit.
Signature of Applicant
Date
iwhaulerapp.doc • 06/17
Application for Septage Hauler Permit • Page 1 of 1