Document Number: DWU-FRM-006-PALS.LW Revision Number: 1 Approved By: Maurice Akech Effective Date: 07/29/10 Description of Last Change: Initial Release Document Title: Transporter Permit Application CITY OF DALLAS WATER DEPARTMENT LIQUID WASTE PROGRAM APPLICATION FOR LIQUID WASTE TRANSPORTATION PERMIT 1. Name of Business 2. * Location of Business 3. City State Zip 4. Mailing Address of Business 5. City State _ Zip 6. Name of Owner 7. Manager of Operation: 8. Manager s driver License # State 9. Business Telephone(s) 10. 24 hour Emergency Telephone Email Address: 11. Indicate below all types of liquid waste to be transported: ( ) grease trap ( ) septic tank ( ) sand/grit trap ( ) used oil ( ) chemical/portable toilet ( ) other (Specify) 12. TCEQ # EXPIRATION DATE 13. Please provide a copy of your Texas Commission on Environmental Quality (TCEQ) registration. 14. List a complete address of disposal site(s) to be used by the vehicle(s) on this permit application. (Information must include contact person and phone number for each site) Page 1 of 5 Pages
FEES Deposit for Excess Flow $500.00 Septage charge - $4.50 per 100 gallons Vehicle Permit(s) 1 st - $220.00; Each Additional Vehicle - $220.00 Trip Ticket Books $10.00 Each * Note: P.O. Boxes are not acceptable. 15. Within the five years preceding the date of this application, have you been convicted of a misdemeanor or felony that has been punishable by confinement and/or a fine exceeding $500.00 and which directly relates to the duty or responsibility in operating a liquid waste transportation business? Yes ( ) No ( ) Explain If Yes: 16. Do you currently have fines or charges pending from other municipalities relating to the liquid waste transportation business? Yes ( ) No ( ) Explain If Yes: 17. Complete the attached Drivers License List on page 3 and List of Vehicles to be Permitted on Page 4 show all information requested for each driver and vehicle to be permitted. 18. Total number of vehicles to be permitted today: 19. You must provide COPIES of the following documents: Proof of Insurance of all vehicles to be used by your company. Operation Manager s driver s license. TCEQ Sludge Transporter Registration issued to your company for transportation of liquid waste. Page 2 of 5 Pages
DRIVER LICENSE LIST Name of Business: (Please list all vehicle drivers information below) Drivers Name License Number State Expiration Date Page 3 of 5 Pages
Name of Business LIST OF VEHICLES TO BE PERMITTED Dallas Permit Vehicle Make Unit Gallons License Plate Vehicle/Trailer # Number# Year Model Number Waste/Water Number Identification Number Page 4 of 5 Pages
20. CERTIFICATION STATEMENT: This application is to be signed by the Owner of the business, Officer of a corporation, or Acting Agent for the business, after adequate completion of this form and review by the person signing below, assuming all responsibilities. I have viewed and accepted all information submitted in this application to be true, accurate and complete. I consent to accept and to abide by all applicable ordinances and regulations of the City of Dallas, Texas. I understand that falsification of any information submitted shall be cause for termination of the liquid waste transport permit. I acknowledge that this permit authorizes the transport of only those liquid wastes listed in item 11 and I understand that no hazardous or industrial waste is to be transported or mixed with liquid waste hauled under this permit. Any person willfully or negligently violating this PERMIT conditions is subject to a fine of Two Thousand Dollars ($2000.00) for each offense. Each day that a violation is permitted to exist shall constitute a separate offense. FURTHERMORE, THE CITY MAY ISSUE NOTICE OF VIOLATION, CONDUCT SHOW- CAUSE HEARINGS, REVOKE THIS PERMIT, AND INITIATE LEGAL ACTIONS TO ENFORCE THE ORDINANCE AND PERMIT CONDITIONS. The City may invoice the PERMITTEE for costs incurred for any cleaning, repair, or replacement work caused by a violation or discharge, and in the event PERMITTEE fails to make payment of any such invoice, the CITY may suspend Liquid Waste Transporter's Permit. I understand that the permit is valid for (1) one year and must be renewed on an annual basis to maintain a valid permit. Signature of Owner/Acting Agent Date PLEASE RETURN TO: Dallas Water Utilities Liquid Waste Program 1020 Sargent Road Bldg. #5 Dallas, Texas 75203 If you have any questions or need any assistance in completing this application please call (214) 243-2374. Page 5 of 5 Pages