Massachusetts Department of Environmental Protection
Bureau of Waste Site Cleanup
BWSC112B
BILL OF LADING (pursuant to 310 CMR 40.0030)
SUMMARY SHEET SIGNATURE PAGE
Release Tracking Number
A. ACKNOWLEDGEMENT OF RECEIPT OF REMEDIATION WASTE AT RECEIVING FACILITY OR TEMPORARY STORAGE:
B. ACKNOWLEDGEMENT OF SHIPMENT AND RECEIPT OF REMEDIATION WASTE BY PERSON CONDUCTING RESPONSE
ACTIONS ASSOCIATED WITH THIS BILL OF LADING:
14. Check here if attaching optional supporting documentation such as copies of Load Information Summary Sheets
1. I, ___________________________________________, attest under the pains and penalties or perjury (i) that I have personally
examined and am familiar with the information contained in this submittal, including any and all documents accompanying this
transmittal form, (ii) that, based on my inquiry of those individuals immediately responsible for obtaining the information, the
material information contained in this submittal is, to the best of my knowledge and belief, true, accurate and complete, and (iii)
that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. I/the person or
entity on whose behalf this submittal is made am/is aware that there are significant penalties, including, but not limited to,
possible fines and imprisonment, for willfully submitting false, inaccurate, or incomplete information.
2. By:
3. Title:
6. Check here if the address of the person providing certification is different from address recorded in BWSC112 Section H.
4. For:
5. Date:
(Name of person or entity recorded in Section G
8. City/Town:
10. Zip Code:
9. State:
11. Telephone:
13. Email:
12. Ext:
7. Street:
1. I, ___________________________________________, attest under the pains and penalties or perjury (i) that I have personally
examined and am familiar with the information contained in this submittal, including any and all documents accompanying this
transmittal form, (ii) that, based on my inquiry of those individuals immediately responsible for obtaining the information, the
material information contained in this submittal is, to the best of my knowledge and belief, true, accurate and complete, and (iii)
that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. I/the person or
entity on whose behalf this submittal is made am/is aware that there are significant penalties, including, but not limited to,
possible fines and imprisonment, for willfully submitting false, inaccurate, or incomplete information.
2. By:
3. Title:
4. For:
5. Date:
Revised: 03/10/2010 Page 1 of 1
6. Date of Final Shipment associated with this Bill of Lading:
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
