TOWN LOT # DATE INSPECTED

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF ENVIRONMENTAL PROTECTION

WETLANDS RESTRICTION PROGRAM 1 WINTER STREET, BOSTON, MA 02108

REQUEST FOR ON-SITE INSPECTION

The Department will conduct on-site inspections in the town of from to . Please fill out and send in the following information to the above address. In addition, please telephone the Department, by a time and place for the inspection.

1. Name of owners:

Name of person requesting on-site inspection (if different from owner)

2. Address of person requesting on-site inspection

3. Address of property

4. Telephone # of person requesting on-site inspection home: work:

5. Reason for on-site inspection

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