2013 SEPTIC HAULER-WASTE WATER SERVICES Commonwealth of Massachusetts
GL
City of Salem
Board of Health Kimberley Driscoll
120 Washington Stre4 4th Floor Mayor
SALEM.MA 01970
Septic Haulers Permit
DATE PRINTED: 0 6125/20 1 3
ESTABLISHMENT.NAME: Waste Water Services Inc
File Number:BHF-2013-000026 1997 Bedford Street
Bridgewater MA 02324
LOCATED AT:
SALEK MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes _
SEPTTC HAULER BHP-2013-0476 Jan 1,2031 Dee 31, 2013 $105.00 Truck-International Reg#86390
Year 20 10
Total Rees: $105.00
PERMIT EXPIRES December 31, 2013
Board of Health
IL
Page 1
s �
kY- EM MASSACHUSETTS
>ARD OF HEALTH
gGToN STREET,4�FLOoR
(978) 741-1800
KOvIBERLEY DRISCOLL \ (978)745-0343 Ike
MAYOR `1 l.4 AADt `.. N C AA
LAMYRAAIDIN,RS/RMS,CHO,CP-FS
DEC /A
HEALTH AGENT
EOV�!)
8�OJZ
�o
bhp OP
�.1c , (F
201 J7APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES
FEE: $105 Per Vehicle payable to the City of Salem No Cash
Name of Applicant: I r
Address:
Nacre of Company:
Address: m L rd ?
Type of Vehicle-i n r 1
Gross �VU -__-- nn ++��
Reg.# Year of Make:__C51-0
Substances)Hauled `f f(V.__ —
Route of Travel L I� k) :�n �jb 1 V V T M C10
(must be oompleted) _ — -- -- -
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 TIIEK 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,[ vL FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER THE LAW.
Si tore Date SS#or Federal ID#
a
. __---__________________________________.____-_______-__-.__._-__________________________________________.__________.----___.___.___________._.-_.__.______-_____...___-------
Permit# Check# / ��[ Check Date
Up&ted5n3/11 / i) r