Disponible en françaisSR-E-500E (2018/04) © Queen's Printer for Ontario, 2018

Ministry of TransportationSpecial Vehicle Configuration (SVC) Permit Application Extended Permitting

Dump Semi-TrailersSee Guidelines for Completing the Dump Semi-Trailer SVC Permit Application.

Ministry Use Only

Fee $

Permit #

Date

Y M D Staff Initials

acknowledges and accepts the responsibilities imposed by law on the applicant in relation to the operation of a vehicle or combination of vehicles under the authority of the permit(s) issued pursuant to this application. The applicant further acknowledges that this permit may be suspended, modified or cancelled pursuant to Section 110.3 and/or 110.4 of the Highway Traffic Act.

Signature of Authorized Applicant / Agent Position / Title (if applicable) Date

1. Declaration The applicant certifies that the information contained in this application is true and

2. Applicant InformationCVOR No. or N.S.C. No.

Do you require permit issued in bilingual format? Yes

PRIO Account Number

Company Name (per Articles of Incorporation) or Last Name, First Name)

Street No. & Name or Lot, Con., Twp. City, Town, Village Province / State Postal Code / Zip Code

Tel. No. Fax No. Contact Name Email Address

3. Applicant hereby applies for permit(s) to continue operation of either "End Dump Semi-Trailer" or "Open-Top Hopper Dump Semi-Trailer" under the provisions of Ontario Regulation 413/05, s. 34. as described in Part 4. Permits requested:

Individual Permit(s) @ $440 each per CVOR holder, to operate vehicle(s) permitted under the authority of O. Reg. 413/05 s. 34.

List all semi-trailers to be issued permit(s)Vehicle Make

Date of Manufacture stated on Vehicle Compliance Label VIN (17 characters in length) Trailer Type

End Dump Semi-Trailer

Open Top Hopper Dumps

Semi-Trailer

Additional trailers are listed on separate attachment.4. Permit SpecificsNote: All permits issued will be valid until the end of the vehicle(s) eligibility to operate under the grandfathering provisions of O. Reg. 413/05, s. 34. Grandfather protection for dump semi-trailers manufactured prior to 2003 will end on December 31, 2010. End dump semi-trailers manufactured between 1996 and 2002 (inclusive) and open-top hopper dump semi-trailers manufactured between 1991 and 2002(inclusive) are eligible for extended grandfathering by special permit and may continue to operate at existing weight allowances until the end of the year in which the trailers reach 15 years or 20 years of age respectively. The operator to which this permit is issued will be exempt from Highway Traffic Act Regulation 413/05 subsections 27(2) and (3) (until June 30, 2011) and section 23.1 (after June 30, 2011) when operating a tractor-trailer combination. The permit is valid only if the date of manufacture on the manufacturer’s label affixed to the semi-trailer matches the month and year of manufacture specified on the permit. An End Dump Semi-Trailer means a semi-trailer to which is permanently attached a body or box that is hinged and can be raised to dump from the rear of the semi-trailer. An Open-Top Hopper Dump Semi-Trailer means a semi-trailer to which is permanently attached an open-top body or box with bottom hoppers that can be opened to dump from the bottom of the semi-trailer.5. Payment and delivery optionsMethod of Payment: Cheque Credit Card Prepaid AccountMethod of Permit Delivery: Picked up E-mailed FaxedComments - Ministry use only

Personal information in this form is collected under the authority of Section 205 of the Highway Traffic Act and is used to evaluate eligibility to obtain a Special Vehicle Configuration permit(s). Direct enquiries to: Weight & Load Engineer, MTO, Carrier Sanctions & Investigation Office, Oversize/Overweight Permit Section, 301 St. Paul St., 3rd floor, St. Catharines, ON L2R 7R4 416-246-7166 / 1-800-387-7736.

SR-LV-034E (2018/05) © Queen's Printer for Ontario, 2018 Disponible en français

Credit Card Authorization Form

Applicant's Information

Name / Company / Dealer

Street No. and Name, P.O. Box, R.R. or Lot, Con. and Twp. Apt. / Suite No.

City, Town or Village

Postal or Zip Code Prov. or State Country

Alternate Phone No.Daytime Phone No.Email

Office Use Only

Operator No. Office No.

Business DateY M D

Fee Paid

Provide one (1) of the following Ontario identification numbers below. If you do not have any of the information requested below check R the "Not Available / None of the above" box.

Driver's Licence (DL) Number:

Licence Plate Number:

Registrant Identification Number (RIN): Dealer Number:

National Safety Code (NSC) Number:

Commercial Vehicle Operator's Registration (CVOR) Number:

Motor Vehicle Inspection Station (MVIS) Number:

Vehicle Identification Number (VIN):

Not Available / None of the above

Under provincial legislation, a false statement from the applicant may result in a penalty.The personal information provided by you on this form is collected to assist with payment verification for the Ministry of Transportation’s driver, vehicle and carrier products and services, for which the Ministry is responsible under the Highway Traffic Act. If you have any questions about the information collected on this form, please contact the Operations Manager, ServiceOntario Driver & Vehicle Contact Centre at 416-235-2999 or 1-800-387-3445 or visit ServiceOntario.ca.

Credit Card Information

Print Name of Cardholder (as it appears on the credit card) Name of Credit Card CompanyVisa Mastercard

Print Name of Signing Authority (if different than name of Cardholder)

Signature of Cardholder and/or Signing Authority

XDate

Y M D

SR-LV-034 2012/05 (p) © Queen’s Printer for Ontario, 2018 Medium Sensitivity when completed

Credit Card Number (Print Clearly) Expiration DateMM YY

SR-E-500E (2018/05)

Instructions For Completing The Extended Permitting Dump Semi-Trailers

These instructions will assist you in completing each section of the permit application.

Section 1. Declaration:

• Authorized applicant must provide signature, indicating the applicant has read, understood and accepted the conditions of the declaration and has authorization to make such declaration on behalf of the carrier.

• Applicant must provide company position/title and the date of application.

Section 2. Applicant Information:

• Enter applicant's Commercial Vehicle Operator's Registration (CVOR) number, Ontario and US base carriers only. All other provinces must provide the National Safety Code (NSC) number. NOTE: Carriers (Ontario and US) without a CVOR must contact:

Ministry of Transportation, Client Services 301 St. Paul Street, 3rd Floor, St. Catharines, ON L2R 7R4 Phone: 416-246-7166 or 1-800-387-7736

• Check applicable box if permit is required in bilingual (French) format.• Enter applicant's company name, complete head office address, telephone number, company fax

number, contact name and e-mail address (if applicable).

Section 3. Vehicle Description

• Indicate the number of individual permit(s) required @ $440 each.• List each Vehicle Make, Date of Manufacture stated on Vehicle Compliance Label, VIN (vehicle

identification number) must be the industry standard 17 characters in length and indicate the type of trailer (End Dump or Open Top Hopper Dump Semi-Trailer).

• Check box if additional trailers require a permit and supply on a separate sheet the information above for each additional trailer.

Section 4. Permit Specifics: Indicates Permit conditions only

Section 5. Payment and delivery options:

• Check applicable box to indicate method of payment. All personal cheques must be certified unless payment is sent by mail.

• If paying by credit card, the Credit Card Authorization Letter must be submitted along with the application form and send by fax at 905-704-2545, e-mail at: oo.permit.department@ontario.ca or by mail at: the Ministry of Transportation (MTO) O/O Permit Office, 301 St. Paul St. 3rd floor, St. Catharines, Ontario, L2R 7R4. All enquiries are to be directed to 1-416-246-7166 or 1-800-387-7736.

• Check applicable box to indicate the method the permit(s) is/(are) to be delivered.