2014 SEPTIC HAULER-FLUSH LL
co-
a W m
� Co
CM
to r
s'm J.
Im
+• tlJ C O.N C Ic
`
a O LUY
AM
C
cc a,
o � LL .
' r c d
mcnIt-� E .a
e � _
m y o ya
C1 .. �.
U �
Y r,=
d
am,
O .O N
W
r LL :�
a a +� ME
i <<�. CITY OF SALEM, MASSACHUSETTS lu
\ BOARD OF HEALTH
1ASHINGTON STREET 4m FLOOR Pubi1CHealth
Prevent.Promote.Protect.
TEL. (978)741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL MAR 31 2014 lrgmdin(S)saleln.corn LARRY RAMDIN,RS/REHS,CHO,CP-FS
MAYOR HEALTH AGENT
L.i IY OF SALE`N
BOARD OF HEPJH
APPLICATION FOR A PERMIT TO TRANSPORT OFFENSIVE SUBSTANCES
FEE: $105 Per Vehicle payable to the City of Salem No Cash
Name of Applicant: Flush LLC
Address: 75 Main Street North Reading MA 01864 Tel#: 978-778-8000
Name of Company: SAME
Address: SAME Tel#: SAME
Email Address FlushServicesA_gmail.com or jamesberrior!u me.com
Type of Vehicle FORD PORTABLE TOILET PUMP TRUCK
Gross Weight 20 000
Reg.# R10655 Year of Make: 2013 F550
Substance(s)Hauled Sep is waste from Portable Toilets
Route of Travel We will be enterin S� alem..coming from North Reading on Rt 128 to Rt 114 to Salem then proceed to job site
to be determined in the City of Salem._
Schedule of Travel April 15 thru Nov 15 of 2014
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 1,TO MY BEST KNOWLEDGE AND
BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER THE LAW.
r4
46-2666993
Signature AfQtsak-J --S 9oLcg- Date SS#or Federal ID#
Permit# Check# Check Date _
Updated 11/20/13