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
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