Bwcs126, Miscellaneous Document Transmittal Form (Page 3 of 4) in pdf

Bwcs126, Miscellaneous Document Transmittal Form Page 3

Massachusetts Department of Environmental Protection

BWSC126

Bureau of Waste Site Cleanup

Release Tracking Number

Miscellaneous Document Transmittal Form

D. PERSON MAKING A SUBMITTAL:

1. Check all that apply:

a. Change in contact name

b. Change of address

c. Change in person

undertaking response actions

2. Name of Organization:

3. Contact First Name:

4. Last Name:

5. Street:

6. Title:

7. City/Town:

8. State:

9. Zip Code:

11. Ext:

12. Email:

10. Telephone:

13.

Check here if the person is a Public Involvement Petitioner

E. RELATIONSHIP TO SITE OF PERSON MAKING SUBMITTAL:

Check here to change relationship

1. RP or PRP:

a. Owner

b. Operator

c. Generator

d. Transporter

e. Other RP or PRP

Specify:

2. Fiduciary, Secured Lender or Municipality with Exempt Status (as defined by M.G.L. c.21E, s.2):

3. Agency or Public Utility on a Right of Way (as defined by M.G.L. c.21E, s.5(j))

4. Any Other person Undertaking Response Actions:

Specify Relationship:

F. CERTIFICATION OF PERSON MAKING SUBMITTAL:

1. I, ___________________________________________, attest under the pains and penalties or perjury (i) that I have personally

examined and am familiar with the information contained in this submittal, including any and all documents accompanying this

transmittal form, (ii) that, based on my inquiry of those individuals immediately responsible for obtaining the information, the

material information contained in this submittal is, to the best of my knowledge and belief, true, accurate and complete, and (iii)

that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. I/the person or

entity on whose behalf this submittal is made am/is aware that there are significant penalties, including, but not limited to,

possible fines and imprisonment, for willfully submitting false, inaccurate, or incomplete information.

2. By:

3. Title:

Signature

4. For:

5. Date:

(Name of person or entity recorded in Section D)

(mm/dd/yyyy)

6. Check here if the address of the person providing certification is different from address recorded in Section D.

7. Street:

8. City/Town:

9. State:

10. Zip Code:

11. Telephone:

12. Ext:

13. Email:

Revised: 09/17/2013

Page 3 of 4

Bwcs126, Miscellaneous Document Transmittal Form Page 3

Related Articles

Related forms

Related Categories