Town of Marshfield
Board of Health
870 Moraine Street
Marshfield, MA 02050
781-834-5558
Fax 781-837-6047
SEPTAGE HAULER APPLICATION
PLEASE Completely fill out application and Worker’s Compensation Form
Fee: $75.00 per truck
Name:_________________________________________________________________
Home Address: _________________________________________________________
Home Phone: ___________________________________________________________
Business Name: _________________________________________________________
Business Address: _______________________________________________________
Business Phone: _________________________________________________________
Cell Phone/Beeper:______________________________________________________
List all pumping vehicles with Year, Make, Vehicle ID and Gallonage Capacity:
1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________
Date of Vehicle Inspection: _______________________________________________
List all locations where septage will be disposed of (include a copy of the contract or written approval for
use of such disposal location):
________________________________________________________________________________________________________________________________________________NOTE: INTERCOMMUNITY DISPOSAL…….The contents of any vehicle licensed herein may be disposed
of in a sanitary manner in any other city or town subject to the written approval of the
MARSHFIELD BOARD OF HEALTH and the written approval of the Authority having control of
the disposal site.
{Title 5, 15.19 (51)}
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 of by the Board as an amendment to this permit.
I hereby acknowledge that all of the above information is true and that I, as an individual or corporation, do not owe the Town of Marshfield any outstanding property taxes and / or other assessments.
Date______________________________Signature of Applicant _________________________________________
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