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.

    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.

    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