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BWSC127
1. Release Tracking Number:
Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup
ACTIVITY AND USE LIMITATION (AUL) PROPERTY
OWNERSHIP UPDATE FORM
Page 1 of 1
A. PROVIDE THE FOLLOWING INFORMATION AS IT APPEARS ON TH E AUL COMPLIANCE LETTER:
5. Disposal Site Address :
5. City/Town: 6. ZIP Code:
Revised: 01/19/2010
3. Name of Company or Organization (if applicable) :
1. Contact First Name:
B. PROVIDE ANY INFORMATION YOU HAVE ABOUT TH E CURRENT OWNER:
7. Telephone:
C. CERTIFICATION OF PERSON MAKING THE SUBMITTAL:
1. I, _________________________________________________________________(print or type first and last name), attest under
the pains and penalties of perjury (i) that I am not the owner of said property(ies), subject to the AUL, and (ii) that the material
information contained in this submittal is, to the best of my knowledge and belief, true, accurate and complete. I/the person or entity
on whose behalf this submittal is made an/is aware that there are significant penalties for willfully submitting false, inaccurate,
or incomplete information.
2. Last Name:
2. Your Name :
3. Name of Company or Organization (if applicable) :
6. City/Town :
4. Street Address:
MassDEP
Bureau of Waste Site Cleanup
One Winter Street
Boston, MA 02108-4747
Once you have completed and signed this form, please mail it to:
Signature
3. Date:
2. By:
mm/dd/yyyy
