non-franchise solid waste collection ......non-franchise solid waste hauler bond section 11: terms /...

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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION 2120 DIAMOND BOULEVARD, SUITE 200

CONCORD, CA 94520 (925) 692-2500 PHONE | (925) 692-2502 FAX

http://www.cchealth.org/eh

NON-FRANCHISE SOLID WASTE COLLECTION & TRANSPORT APPLICATION (APPLICATION FEE IS DUE AND NON-REFUNDABLE)

SECTION 1: APPLICATION TYPE New Renewal SECTION 2: CONTACT INFORMATION A. Applicant Information

APPLICANT NAME :

APPLICANT ADDRESS :

CITY / STATE / ZIP CODE : PHONE # : FAX # :

APPLICANT EMAIL :

B. Business Information (If Sole Proprietor, provide a copy of a valid fictitious business name statement for the business. All others, provide written documentation that the entity may lawfully conduct business in the unincorporated area.)

BUSINESS NAME : CORP INC LLC LP SOLE PROPRIETOR

BUSINESS ADDRESS : EMPLOYER IDENTIFICATION NUMBER (EIN) :


BUSINESS EMAIL :

CARRIER IDENTIFICATION NUMBER (provide proof of possession, if applicable) : US DEPT. OF TRANSPORTATION (DOT) NUMBER (if applicable) :

BUSINESS MAILING ADDRESS (if different from above) :

CITY / STATE / ZIP CODE :

SECTION 2: REFUSE HAULING VEHICLE(S) A. Vehicle Information (if more than 10, attach separate sheet)

Vehicle No. Make Model License Plate # Vehicle Identification # Roll-Off Box

**Note: Attach copies of valid California vehicle registration cards for each vehicle.

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B. Location Where Vehicle(s) Are Stored

STREET ADDRESS :

CITY / STATE / ZIP CODE :

SECTION 3: REFUSE HAULING VEHICLE OPERATOR(S) A. Operator Information (if more than 10, attach separate sheet)

Operator’s Name Driver’s License No. Operator’s Name Driver’s License No.

**Note: Provide documentation of each operator’s legal authority to operate a refuse hauling vehicle, including copies of valid California Driver’s Licenses. SECTION 4: WHERE DO YOU PROPOSE TO PROVIDE PICK-UP & HAULING SERVICES IN THE COUNTY UNICORPORATED AREA?

(Numbered Territories correspond to service areas shown on the attached map. Check all that apply.) All Hauling Territories (1-9) Hauling Territory 4 Hauling Territory 8 Hauling Territory 1 Hauling Territory 5 Hauling Territory 9 Hauling Territory 2 Hauling Territory 6 Hauling Territory 10 Hauling Territory 3 Hauling Territory 7

SECTION 5: WHAT TYPES OF CUSTOMERS/LOCATIONS DO YOU PROPOSE TO SERVE? (Check all that apply) Residential Commercial Industrial Governmental Agricultural Other: _____________________

SECTION 6: WHICH TYPE(S) OF WASTE DO YOU PROPOSE TO COLLECT & TRANSPORT TO APPROVED LOCATION(S)? (Check all that apply) **Note: No permit required for waste or materials that your company would NOT charge customers to remove, transport, or properly recycle/dispose of. DO NOT complete the remainder of the application if solely proposing to offer free pick-up services.

Household Trash (Municipal Solid Waste) Scrap Metal Cardboard / Paper Mixed Commercial Waste / Trash Construction / Demolition Debris Furniture / Mattresses Electronic Waste (E-Waste) Green Waste / Wood Waste Other: _____________________ Contaminated Soil Appliances (White Goods) Other: _____________________ Non-Hazardous Industrial Waste Bottles / Cans Other: _____________________

SECTION 7: SERVICE(S) PROVIDED A. Will you provide any on-site service (e.g. junk removal, site clean-up, etc.) related to the above type(s) of waste to be hauled away?

No, the company will only offer to haul away waste placed out for pick-up by customers. (Skip to Section 8) Yes. Please describe these services below:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. Will you charge customers for any on-site service(s) noted above? No, related on-site service(s) noted in Section 7A will be offered and provided to customers free of charge. Yes, there will be a charge to customers for on-site service(s) noted in Section 7A.

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SECTION 8: LOCATION(S) WHERE SOLID WASTE IS TRANSPORTED (if more than 4, attach separate sheet)

Facility Name Address

SECTION 9: BOND & INSURANCE REQUIREMENT A. Performance Bond Information (Provide copy of the Non-Franchise Solid Waste Hauler Bond form)

SURETY COMPANY NAME :

SURETY COMPANY ADDRESS :


POLICY NUMBER : EFFECTIVE DATE :

B. Liability Insurance Information (Provide proof of liability insurance)

INSURANCE COMPANY NAME :

INSURANCE COMPANY ADDRESS :


POLICY NUMBER : EFFECTIVE DATE : EXPIRATION DATE :

SECTION 10: SUPPLEMENT DOCUMENTS REQUIRED (If applicable) Fictitious Business Name Statement California Driver’s License(s) Proof of Liability Insurance Proof of Valid Motor Carrier Identification Map of Intended Service Area Other : ___________________ Vehicle Registration Card(s) Non-Franchise Solid Waste Hauler Bond

SECTION 11: TERMS / SIGNATURE

The undersigned hereby certifies that all of the information provided on this application is true and accurate, and agrees to notify Contra Costa Environmental Health of any changes that occur including, but not limited to, the type(s) of business activity, business name, business address, vehicle(s), vehicle storage location, liability insurance coverage, performance bond, business ownership, and/or closure. The signature below must be from an owner, partner or corporate officer (for corporations and limited liability companies). A manually signed copy of this application delivered by facsimile, email, or other electronic transmission shall be deemed to have the same legal effect as delivery of an original signed hard copy of this application. APPLICANT NAME (Please print) : _______________________________________________________________________________ SIGNATURE OF APPLICANT: ______________________________________________________ DATE : _____________________

FOR OFFICE USE ONLY SR#: FA#: PR# : P/E: EHT: RECEIVED BY: DATE RECEIVED:

AMOUNT DUE:

$ AMOUNT PAID:

$ CHECK #: METHOD OF PAYMENT:

CASH/CHK MC VISA D/C RECEIPT #:

XR MED WASTE APP (REV. 2/9/2018)

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non-franchise solid waste collection ......non-franchise solid waste hauler bond section 11: terms /...

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