2013 SEPTIC HAULER-DAVE'S SEPTIC SERVICE Commonwealth of Massachusetts
e �
City-of Salem
Kimberley Driscoll
Board of Health Mayor
120 Washington Street,4th floor
SALEM,MA 01970
Septic Haulers Permit
DATE PRINTED: 06/25/2013
ESTABLISHMENT NAME: Dame's Septic Service
File Nuirnbm 81-{F2013-000025 P.O. Box 5793
- - MANCHES — 8
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee .Restrictions 1 Notes
SEPTIC IIAULER BHP-2013-0475 Jun 13,2013 Dec 31, 2013 $105.00
Total fees: $105.40
PERMIT EXPIRES Pecember3l, 2013
Board of Health
Page 1
j�
s CITY OF SALEM, M.ASSAC:EI:USETTS
BOARD OF HEALTH
F 120 W'ASHINGrON STREET',4 LOOR Publ1CHP�t1
Prevent.Promote.Protect.
TEL. (978)741-1800 FAX(978) EI !!E®
lramdin .salem.com
I�IMI3ERLEY DKISCOLT, LARRY-RA.1VmIN,.RS j.RE.T-Is,CT ro,CP-F
MAYOR JUN 17 2013 HEAl.mi AGENT
APPLICATION FOR A PERMIT TO TRANSPORT-OF S i AMSTANCES
FE`.' $105 P Vehicle payable to the City of Salem No Cash
Name of Applicant:
Address: Tel#:_��
Name of Company: VV J� r
Addres I Tel#:
Type of Vehicle
Gross Weight .
Reg.# Year of Make_
Substance(s)Hauledt
Route of Travel
(must be completed) f �y
Schedule of Travel
I HAVE READ THE BOARD OF HEALTH REGULATIONS,"RULES AND REGULATIONS FOR TRANSPORTIING OFFENSIVE
SUBSTANCES."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REGULATIONS. I
UNDERSTAND THEM;AGREE TO ABIDE BY THEM AND UNDERSTAN THAT FAILURE TO DO SO MAY RESULT IN
REVOCATION OF MY PERMIT TO CARRY OFFENSIVE SUBSTANCES.
PURSUANT TO HGL C62C, S49A I CERTIFY UNDER THE PENALITIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND
BELIEF,HAVE F .ED ALL TATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER THE LAW.
lg ure Date SS# or Federal ID#
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Permit# Check# /d �/ Check Date
Updated 5/23/11