City Of Watsonville Application For Mobile Waste Hauler Discharge Permit Application

2. 1. General Information
4. Applicant (Name of Business)
5. Name(s) of Owner(s)
7. Federal Tax ID #:
8. Telephone Number
9. Email address
11. Mailing Address
13. City
14. State
15. Zip Code
17. Facility Location
19. City
20. State
21. Zip Code
23. Telephone Number
24. Fax Number
26. Email Address
28. 2. Geographic area served:
30. 3. Waste Transport Vehicle Information
    List the model, license No., and capacity (Gal.) of your vehicle(s) below.
32. Model
33. License No.
34. Capacity (Gal.)
35. Waste Type
    -- Select One --Domestic SeptageChemical ToiletRestaurant GreaseOther
37. Model
38. License No.
39. Capacity (Gal.)
40. Waste Type
    -- Select One --Domestic SeptageChemical ToiletRestaurant GreaseOther
42. Model
43. License No.
44. Capacity (Gal.)
45. Waste Type
    -- Select One --Domestic SeptageChemical ToiletRestaurant GreaseOther
47. Model
48. License No.
49. Capacity (Gal.)
50. Waste Type
    -- Select One --Domestic SeptageChemical ToiletRestaurant GreaseOther
52. Model
53. License No.
54. Capacity (Gal.)
55. Waste Type
    -- Select One --Domestic SeptageChemical ToiletRestaurantOther
57. 4. Waste Hauler Transports and Disposes Of The Following Category(ies) of Waste:

    1. Domestic Septage
    2. Chemical Toilet
    3. Restaurant Grease
    4. Other (Specify in notes below)
59. Notes
61. If using a chemical toilet additive, attach Safety Data Sheet (SDS) here
63. 5. Existing Permit(s) or Authorization for Disposal of Waste:
    Type in the Permit No., Issuing Agency, and Expiration Date below: REQUIRED: Health Department permit if hauling septage OR Inedible Kitchen Grease certificate if hauling grease.
65. Permit No.*
66. Issuing Agency*
67. Expiration Date*
    Expiration Date
69. Permit No.
70. Issuing Agency
71. Expiration Date
    Expiration Date
73. Permit No.
74. Issuing Agency
75. Expiration Date
    Expiration Date
77. 6. Non-Domestic Customer information for waste to dispose of at City of Watsonville Wastewater Treatment Facility
79. Customer Name
80. Type of Operation
81. Type of Waste
82. Volume in Gallons
84. Customer Name
85. Type of Operation
86. Type of Waste
87. Volume in Gallons
89. Customer Name
90. Type of Operation
91. Type of Waste
92. Volume in Gallons
94. 7. Administrative Official Employed by Applicant Responsible for Disposal of Hauled Waste
96. First Name, Last Name
97. Position
99. Phone Number
100. E-mail address
102. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree to the terms listed below and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. TERMS A. The Permit Holder shall pay disposal rates based on the waste type as it corresponds to the City of Watsonville Fee Schedule. B. Disposal rates are based on the full volume of the waste tank on the transport vehicle. C. Payment of fees and charges are due when billed by the City and considered past due after 30 days. D. Overdue accounts may be referred to an outside agency to enforce payment. E. City of Watsonville may amend fees and charges during the term of the Permit. F. All mobile waste hauler discharges must comply with City of Watsonville Sewer Service Ordinance 6-3.513. G. All discharges must be documented on a Mobile Waste Hauler Load Identification Report.

     1. I agree.
104. Electronic Signature*
105. Title or Position
106. Date*
     Date
Leave This Blank:


108. 1. Receive an email copy of this form.
109. Email address

     This field is not part of the form submission.

110. Submit Submit and Print

* indicates a required field