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Data Disclosure Form Septage Haulers Name of Business: Address of Business: Mailing Address: Phone Number: Contact Person: Average Number of Residential homes daily: Do you haul wastes from Businesses: How often: Type of waste hauled: *Vehicle Description: *Vehicle Number: *Tank Capacity: List any permits issued to this business: *If there is more than one vehicle used to haul wastes include the vehicle number and tank capacity on a separate sheet of paper. If there is no vehicle number use the vehicle license plate number. Signature: Date: INCLUDE: A copy of an updated hauler manifest with this application.