Fill in a Valid Fp 300 Massachusetts Form

THE COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF FIRE SERVICES

Application for Permit to Process Hazardous Materials

FP-300

(Rev. 02/12)

Company Information:

Company Name: _______________________________________________________________________________________

Street Address: ________________________________________________________________________________________

Responsible Party:

Official Title:

In accordance with 527 CMR 33, 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

I attest that as the responsible official for the company named above that the facility is in compliance with the applicable requirements of 527 CMR 33 and other applicable provisions of 527 CMR and MGL 148. Further, I herby certify that I am authorized to execute this application. I 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:

THE COMMONWEALTH OF MASSACHUSETTS

City or Town: ________________________________Date: _________________ Permit Number (if applicable): _________

In accordance with the provisions of M.G.L. Chapter 148, as provided in 527 CMR 33 this permit is granted

to ________________________________________________________________________________________

(Full Name of Person, Firm or Corporation)

at ________________________________________________________________________________________

(Street and # or Describe Location for Adequate Identification)

for the processing of hazardous materials.

CATEGORY 2 CATEGORY 3 CATEGORY 4 CATEGORY 5

Fee Paid $ _____________________________ This Permit will expire on _______________________________

Signature of Official Granting Permit: __________________________________Title ______________________

This permit must be conspicuously posted upon the premises