2. Hazardous Materials Registration Form (HMRF)

   A hard copy of your invoice has been mailed out on 1/21/22 to the addresses that the Board of Health has on file. 

   If you have not received your invoice yet and wish to calculation your registration fee invoice amount, please see the below fee amounts:

   • Hazardous Waste Generator: VSQG = $50, SQG = $50, LQG = $100
   • Underground Storage Tanks; Number of tanks: $50 per tank
   • Chemical Storage Amounts: Less than 300 gallons = $50, Greater than 300 gallons= $100

   If you have any questions or if you do not receive your invoice in the mail, please contact the Board of Health office at 781-270-1955.

6. Date*
   Date
8. Facility Name*
9. Type of Business*
11. Facility Address*
13. City*
14. State*
15. Zip Code*

17. HMRF Preparer Information

19. Name*
20. Title*
22. Mailing Address*
24. City*
25. State*
26. Zip Code*
28. Phone Number*
29. Fax Number
30. Email Address*

32. List TWO emergency contact personnel for your facility.

34. Contact #1 Name*
35. Contact #1 Title*
37. Contact #1 Phone Number*
38. Contact #1 24 Hour Phone Number*
40. Contact #1 Email Address*
41. Contact #1 Fax Number
45. Contact #2 Name*
46. Contact #2 Title*
48. Contact #2 Phone Number*
49. Contact #2 24 Hour Phone Number*
51. Contact #2 Email Address*
52. Contact #2 Fax Number

54. Registration Fee Calculation (Please check all that apply to your facility)

56. Hazardous Waste Generator*

    1. Yes
    2. No
57. If yes, check all that apply

    1. VSQG (less than 27 gallons/month) ($50)
    2. SQG (27 to 250 gallons/month) ($50)
    3. LQG (greater than 250 gallons/month) ($100)
59. Underground Storage Tanks*

    1. Yes
    2. No
60. If yes, List the Number of Tanks ($50 per tank)
62. Chemical Storage Amounts*

    1. Yes
    2. No
63. If yes, check all that apply

    1. Less than 300 Gallons ($50)
    2. Greater than 300 Gallons ($100)

65. Hazardous Waste Generator Status

67. Does your facility generate chemical or hazardous waste? (If no, skip to Chemical Storage section)*

    1. Yes
    2. No
68. Indicate your generator status

    1. VSQG (less than 27 gallons/month)
    2. SQG (27 to 250 gallons/month)
    3. LQG (greater than 250 gallons/month)
69. List your EPA or DEP Generator Identification Number
71. Fill out the blank table listing all hazardous waste present at your facility and upload here (preferably in a PDF format).*

72. BLANK FILLABLE PDF ATTACHED HERE

74. Chemical Storage

76. Does your facility handle, use or store chemicals (e.g., oils, solvents, acids/bases, cleaning agents, fuels or compressed gas cylinders)?*

    1. Yes
    2. No

78. If, in the last calendar year, you stored greater than 10,000 pounds of any hazardous chemical for which you are required to maintain a Safety Data Sheet (SDS) or 500 pounds of an Extremely Hazardous Substance, your facility is required to file a Tier II Emergency and Hazardous Chemical Inventory in accordance with US EPA Emergency Planning and Community Right-to-Know ACT (EPCRA) requirements. 

79. Will your facility be filig a Tier II form for last year?*

    1. Yes
    2. No
81. If yes, please upload Tier II Inventory Information here (preferably in a PDF format).

    A copy should also be sent to the Burlington Fire Department.

83. Does your facility store compressed gas cylinders?*

    1. Yes
    2. No
84. Does your facility store flammable materials?*

    1. Yes
    2. No
85. Does your facility have any ABOVE GROUND storage tanks?*

    1. Yes
    2. No
87. If yes, complete the blank table for above ground storage tanks and upload here (preferably in a PDF format).

88. BLANK FILLABLE PDF ATTACHED HERE

90. Upload a list of all chemicals present at your facility stored in quantities equal to or greater than 1 liter (33.8 ounces) or 1 kilogram (2.2 pounds) (preferably in a PDF format).

91. BLANK FILLABLE PDF ATTACHED HERE

93. Underground Storage Tanks

95. Does your facility have any UNDERGROUND storage tanks?*

    1. Yes
    2. No
97. If yes, complete the blank table for underground storage tanks and upload here (preferably in a PDF format).

98. BLANK FILLABLE PDF ATTACHED HERE

100. Sewer Discharge Permit

102. Does your facility have any of the following types of permits for the Massachusetts Water Resources Authority (MWRA) Group, General or Sewer Use Discharge Permit?*

     1. Yes
     2. No
103. If yes, please attach a copy of permit

105. General Facility Information

107. List spill clean-up materials and equipment present on-site
109. 1.*
110. 2.
111. 3.
113. List potential spill pathways for chemicals to enter the environment (e.g. floor drains, dry wells, cracked pavement, loading docks)
115. 1.*
116. 2.
117. 3.

119. Facility Maps

121. Attach a simple floor plan of the INTERIOR of your facility indicating the locations where hazardous materials are handled or stored. Indicate the location of chemical storage areas, compressed gas cylinders, spill control equipment, flammable storage areas/cabinets, and hazardous waste storage areas. Please note any special hazards that threaten emergency response personnel within these areas. Note any special hazards that threaten emergency response personnel.*
123. If applicable, please attach a site map indicating the location(s) of storage tank(s) and other hazardous materials or wastes stored OUTDOORS.
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit Submit and Print

* indicates a required field