2009 DISPOSAL WORK’S INSTALLER’S PERMIT RENEWAL

Please fill in and return this application along with a check in the amount of $125.00 by December 31, 2008, to be made payable to the Town of Westminster and return both the check and completed application to the following address:

Town of Westminster

Board of Health

11 South Street

Westminster, MA 01473

I hereby apply for a Disposal Work’s Installer’s Permit as required by 310 CMR 15. 019 of the revised Title 5 of the State Environmental Code, which became effective on March 31, 1995

PLEASE PRINT ALL INFORMATION BELOW

Owner’s Name: ________________________________________________

Business Name: ________________________________________________

Licensed Installer: ________________________________________________

Mailing Address: ________________________________________________

Business Telephone: ________________________________________________

Home Telephone: ________________________________________________

The undersigned agrees to abide by the requirements of Title 5 of the State Environmental Code as revised and became effective March 31, 1995, and its subsequent revisions. The undersigned also understands that any violation of Title 5, or the Board of Health Regulations, will be sufficient cause for revocation of his/her Installer’s Permit.

Date:___________________ Signature:_______________________