Town of Raynham, Massachusetts
558 South Main Street, Raynham, MA 02767
ph: 508.824.2707
Septage Hauler Application
Commonwealth of Massachusetts Application for Septage Hauler                                                                                                           
Fee: $125.00
                                                                        
In accordance with MGL c. 111, Section 31B, and 310 CMR 15.502 (Title V), the undersigned makes application to the Board of Health or approving authority for
permission to remove and transport septage and the content of privies and cesspools as set forth below.

Applicant Information

Company Name_______________________________________________________________________________________________________________________________________

Address_____________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

Phone Number_______________________________________________________________________________________________________________________________________

Mailing Address_______________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________


Number and Types of Equipment and their gallon capacity:

_____________________________________________________________________________________________________________________________________________   
Number                          Type                            Gallonage
_____________________________________________________________________________________________________________________________________________
Number                          Type                            Gallonage
______________________________________________________________________________________________________________________________________________
Number                          Type                            Gallonage


**Areas from which septage will be accepted (append customer list):__________________________________________________________________________________________

Location of final disposal of septage: ___________________________________________________________________________________________________________________

Certification:
I certify that the information I have provided above is true and accurate.  I recognize that it is a violation of this permit to dispose of septage anywhere other
than the identified disposal locations or others approved by the Board in writing as an amendment to this permit.



_________________________________________________________________________________________________________________________________________________
Signature of Applicant                                          Date

Pursuant to MGL Ch. 62C, Sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.

Social Security Number or Federal ID: _____________________________________________________________________________________________


Signature of Individual or Corporate Name:_____________________________________________________________________________________________
Please Note: SSN or FID numbers shall be redacted if this application is included in a FOI Request

**New Applications must include three references from other communities’ Boards of Health.