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1 CITY of MODESTO Public Works Department: 1221 Sutter Avenue, Modesto, CA 95351 Environmental Compliance Section (209) 577-6377 Fax (209) 577-6290 LIQUID WASTE HAULER PERMIT APPLICATION 2014-2016 PERMIT NO. Please Type or Print Neatly. 1. Applicant Business Name: 2. City of Modesto Business License Number: 3. Stanislaus County Permit Number: 4. Business Address: City: State: Zip: Mailing Address: City: State: Zip: Phone Number: Emergency Number: Fax Number: 5. Name of Registered Truck Owner: 6. Name of Legal Truck Owner: 7. Individual responsible for application, if other than registered truck owner: Name: Title: Phone: ---PAGE BREAK--- 2 8. Truck Data: (If you operate more than one truck, please include data for each truck) A. Truck B. Tank Capacity (Gallons): C. CA License Plate No: D. Does the truck have an acceptable extension of attachments for dumping directly in the station? Yes If not, what process is used for direct dumping of liquid waste? E. Circle the days of the week that operation/dumping occurs: Sun. Mon. Tues. Wed. Thurs. Fri. Sat. F. Does this vehicle transport any wastes other than household septic tank wastes? Yes If yes, list the other types of wastes (i.e. chemical wastes, oil and grease, used motor oil, etc.). Also list where they originate (i.e. industry, restaurant, gas station, etc.). Type of Waste Name, Address, and Type of Operation Of Non-Domestic Customer ---PAGE BREAK--- 3 G. List all permits or authorizations for the disposal of any wastes listed above: Permit Type and Number Issuing Agency Expiration Date 9. Name of Insurance Carrier: (Auto and General Liability) Address: City: State: Zip: Agent: Phone Number: Has a copy of your Certificate of Insurance been filed with the City of Modesto? Yes (This must be done prior to approval of this permit) 10. Certification: I have personally examined and am familiar with the information contained in this application and believe that the submitted information is true, accurate and complete. In addition, I am aware of the conditions and requirements of the Liquid Waste Hauler Permit and agree to meet them at all times. Failure to comply with Permit Conditions may result in the immediate suspension or revocation of the Liquid Waste Hauler Permit. Signature: Print Name: Title: Date: ---PAGE BREAK--- S:\ENVIRONMENTAL COMPLIANCE\PRETREATMENT\WASTE HAULERS\WH PERMITS\LIQUID WH PERMIT APPLICATION 2014-2016.DOC 4 Liquid Waste Hauler Permit Application Check-off Sheet The following items must accompany this application. If these items are not received with the application, the application will be deemed incomplete and will not be processed. Completed application with Certification Signatures Proof of current liability insurance listing the City of Modesto as a Certificate Holder with the following requirements: General liability insurance with a minimum limit of liability per occurrence of $1,000,000 for bodily injury and $100,000 for property damage or $1,000,000 combined single limit. This insurance shall indicate on the certificate of insurance the following coverage and indicate the policy aggregate limit applying to: premises and operations; broad form contractual; independent consultants and subcontractors; products and completed operations. Automobile liability insurance with a minimum limit of liability per occurrence of $1,000,000 for bodily injury and $100,000 for property damage or $1,000,000 combined single limit. This insurance shall cover any automobile for bodily injury and property damage. Worker’s Compensation in compliance with the statutes of the State of California, plus employer’s liability with a minimum limit of liability of $500,000. if the business is owner-operated, please include a signed statement of this fact to forgo the worker’s compensation requirement. A copy of your current Stanislaus County permit issued by the Department of Environmental Resources A copy of your current business license A copy of current vehicle registration for each septic truck being permitted A copy of the capacity certificate from Stanislaus County Weights and Measures for each septic truck being permitted (new haulers only) Make a $100 security deposit in a trust account at the City of Modesto Finance Department. Provide a copy of the trust action (receipt) with this application (new haulers only) If you have any questions regarding this application, please contact the City of Modesto Environmental Compliance Section at (209)577-6377.