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DEPARTMENT OF FIRE SERVICES
Application for Permit to Process Hazardous Materials
FP-300
(Rev. 1.1.2015)
Company Information:
Company Name:
Street Address:
Responsible Party:
Official Title:
Telephone number: Email:
H
In accordance with 527 CMR 1.00 Section 1.12.8.34.1.2, the above named facility is conducting the following hazardous
material process(es) at the category identified below (Select all categories applicable to the facility):
❑ CATEGORY 2 — Capacity of largest size vessel used in hazardous material process is greater than 2.5 gallons, but
does not exceed 60 gallons
❑ CATEGORY 3 — H Occupancy Classified facility, per 780 CMR Mass Building Code, or capacity of largest size vessel
used in hazardous material process is greater than 60 gallons, but does not exceed 300 gallons
❑ CATEGORY 4 — Capacity of largest size vessel used in hazardous material process exceeds 300 gallons, but is not
covered by Category 5.
❑ CATEGORY 5 — Amount of hazardous material in a process exceeds threshold quantity of 29 CFR 1910.119 or
40 CFR 68
/ attest that as the responsible official for the company named above that the facility is in compliance with the applicable
requirements of 527 CMR 1.00 Section 60.8 and other applicable provisions of 527 CMR and MGL 148. Further, 1 herby certify
that 1 am authorized to execute this application. / declare under the penalty of perjury that the statements and information
provided herein are true as of the date of this application.
Signature of Responsible Party:
Title
Telephone number:
—E5--------------------------------------------------------------
FP-300
City or Town:
PERMIT
Date:
Fire Department
Permit Number (if applicable):
In accordance with the provisions of M.G.L. Chapter 148, as provided in 527 CMR 1.00 Section 1.12.8.34.1.2 this
permit is granted
to
at
(Full Name of Person, Firm or Corporation)
(Street and # or Describe Location for Adequate Identification)
for the processing of hazardous materials.
❑ CATEGORY 2
Fee Paid $
Signature of Official Granting Permit:
❑ CATEGORY 3 ❑ CATEGORY 4 ❑ CATEGORY 5
This Permit will expire on
Title
y This permit must be conspicuously posted upon the premises