HomeMy WebLinkAboutsolid-waste-vehicle-registration-form-adaSolid Waste Program
Alameda County Department of Environmental Health
Solid/Medical Waste Management
1131 Harbor Bay Parkway, Alameda, CA 94502
Phone: (510) 567-6790 Fax: (510) 337-9234
www.acgov.org/aceh
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SOLID WASTE VEHICLE REGISTRATION FORM
TYPE OF WASTE HAULED: (Check all that apply)
MUNICIPAL SOLID WASTE CONSTRUCTION & DEMOLITION
MIXED WASTE ORGANICS RECYCLABLES
SOURCE SEPARATED ORGANICS OTHER
TYPE OF APPLICATION:
NEW RENEWAL
-------------------------------------------------
PERMIT FEE SUBMITTED
FACILITY NAME ______________________________________________________ PHONE NUMBER (______) __________________
FACILITY ADDRESS _______________________________________ CITY ________________________ ZIP CODE ________________
BUSINESS OWNER NAME _______________________________________________ PHONE NUMBER (______) _________________
BUSINESS OWNER ADDRESS _______________________________ CITY ____________ STATE _______ ZIP CODE _______________
MAILING ADDRESS _______________________________________ CITY ____________ STATE _______ ZIP CODE _______________
CONTACT PERSON _____________________________________________________PHONE NUMBER (______) _________________
EMAIL ADDRESS ______________________________________________________________________________________________
VEHICLE PARKING ADDRESS_________________________________________ CITY _____________________ ZIP CODE __________
SOLID WASTE FACILITIES SERVICED IN ALAMEDA COUNTY (WHERE SOLID WASTES ARE PICKED-UP)
Facility Name Address City Zip Code
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PRINT NAME / TITLE ___________________________________________________________________________________________
SIGNATURE___________________________________________________________________ DATE: __________________________
The undersigned hereby applies for a Permit to Operate and ag rees to operate in accordance with all applicable state and local regulations, laws, and
such inspection procedures needed to ensure compliance. Payment of the required fee and late penalties, if any, to secure a valid permit, is required
before commencing or continuing operations. Failure to do so may result in a misdemeanor citation, permit suspension/revocation proceedings,
and/or closure. Notify the Department of Environmental Health of any change in the type of business activity, name, mailing address, or ownership
by calling the number above. PERMITS AND FEES ARE NOT TRANSFERABLE.
LIST THE INFORMATION FOR THE VEHICLES YOU WISH TO REGISTER. (USE BACK FOR MORE SPACE)
MODEL YEAR LICENSE
PLATE
VIN# COMPANY
VEHICLE #
CAPACITY
(TONS)
TYPE OF WASTE
(MSW, C&D, ORGANICS, ETC)
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2
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FOR OFFICIAL USE ONLY
FA# __________________ PR# ________________
AMOUNT PAID: ________ DATE PAID ___________
ENVIRONMENTAL HEALTH SPECIALIST: ____________________________
APPROVED NOT APPROVED DATE: ____________________
Solid Waste Program
Alameda County Department of Environmental Health
Solid/Medical Waste Management
1131 Harbor Bay Parkway, Alameda, CA 94502
Phone: (510) 567-6790 Fax: (510) 337-9234
www.acgov.org/aceh
SOLID WASTE VEHICLE REGISTRATION FORM
Page 2 of ___
MODEL YEAR LICENSE
PLATE
VIN# COMPANY
VEHICLE #
CAPACITY
(TONS)
TYPE OF WASTE
(MSW, C&D, ORGANICS, ETC)
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