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C6 Waste Transporter Authorization Application Metropolitan St. Louis Sewer District Waste Transporter Authorization Application (Please see the instructions on the reverse side of this form) Section A - Company Identification MSD Assigned Transporter ID: 1. Company Name: ________________________________________________________________ 2. Mailing Address: ____________________________________________________________________________________________ Zip Code:______________ 3. Name of Contact Person: Telephone: ( ___ )_____________________ 4. Name and Title of Chief Executive:_______________________________________________________________________________ 5. Premise Address:_____________________________________________________________________________________________ Zip Code: _______________ 6. Activities at this premise:______________________________________________________________________________________ 7. Dispatcher Name: Dispatcher Telephone: ( )_____________________ Section B - Waste Transport Vehicles Vehicle Make Model Tank Volume (gallons) Vehicle License Information St. Louis County HPN MSD Assigned Vehicle ID Number License No. State Expiration Date HPN Expiration Date 1 2 3 4 Section C - Waste Information 1. Types and estimated annual volumes of wastes 2. Areas in which your company to be transported and discharged to MSD: will operate: Industrial Waste _________________ St. Louis City _____ Landfill Leachate _________________ St. Louis County MO _____ Sludge _________________ Jefferson County MO _____ Septic Tanks _________________ St. Charles County MO _____ Portable Toilets _________________ Illinois _____ Grease Traps _________________ Other _______________ _____ Other ______________ _________________ ____________________ _____ Section D - Insurance Attach a certificate documenting that your company has a minimum of $1,000,000 per occurrence comprehensive general liability and auto liability insurance which includes the District as an additional insured and includes provisions for informing the District 10 days prior to the time of policy cancellations or renewals. Section E – Billing For billing purposes, provide a savings account deposit slip for withdrawal or voided check from your checking account to set up your MSD SmartPay Direct Payment program account. The MSD SmartPay Direct Payment program will debit MSD hauled waste charges from your selected bank account each month. Your signature at the bottom of the application hereby authorizes MSD and the financial institution you indicated to deduct from the checking/savings account for hauled waste charges. Certification I have personally examined and am familiar with the information submitted in this document and attachments and certify the information to be true, accurate, and complete. I further agree to operate under provisions of all pertinent District Ordinances and realize failure to do so may result in my discharge privileges being revoked and enforcement action being taken against me. Name and Title of signing official:________________________________________________________________________________ Signature: Date: ___________________ FOR MSD USE ONLY: MSD DEC approval date: ___ MSD billing account number:______________________________________ INSTRUCTIONS FOR COMPLETING WASTE TRANSPORTER AUTHORIZATION APPLICATION PLEASE PRINT ALL INFORMATION Section A: 1. Fill in your legal company name. Leave the MSD Transporter ID number space blank. An MSD Transporter ID number will be assigned at the time your application is approved. 2. Provide your complete business mailing address. This should be the address where you want business correspondence and bills sent. 3. Provide the name of a contact person who can be reached during normal business hours and your business telephone number. 4. Provide the name and title of the company's chief executive officer. 5. Provide the address of the premise from which your waste transporting activities are conducted. If you have more than one site, provide information for your primary site on this form and attach a listing with the addresses and activity information for each additional site. 6. List the activities conducted at each of the premises identified in item 5. These activities might include overnight parking of waste transport vehicles and related equipment, storage or transfer of wastes, servicing of portable toilets and other activities related to transporting liquid wastes to the District. 7. If you have a dispatcher provide the name and telephone number. SECTION B: Provide the required information for each vehicle your company will have in service transporting and discharging wastes to the District. If you have more than four waste transport vehicles use an additional copy of the form or attach a sheet listing the required information. List only vehicles with waste tanks and only those vehicles you intend to discharge at MSD. Do not list tractor units used to pull tank trailers but do list each trailer. Provide a St. Louis County Health Permit Number for each of the above vehicles which will operate in St. Louis County. These numbers must be valid for the current year. Leave the MSD Vehicle ID space blank. MSD Vehicle ID numbers will be assigned at the time your application is approved. SECTION C: 1. Check off the types of waste you transport or expect to transport to the District and estimate, in gallons, the annual volume of each type. 2. Check off the areas in which you currently pick up or expect to pick up wastes for transporting to the District. SECTION D: Attach the required certificate from your insurance company showing a minimum of $1,000,000 per occurrence comprehensive general liability and auto liability insurance. SECTION E: For billing purposes, you will be required to enroll in the MSD SmartPay Direct Payment program. This program is free and will debit MSD hauled waste charges from your selected bank account each month. You will receive your bills and an itemization of charges in the mail for your records. The due date on the bill is the date your selected account will be automatically debited. The MSD SmartPay Direct Payment program will allow you to view your account on the MSD Online Account Management website at www.msd.st-louis.mo.us using an ID and password you select. The web site will show current and past charges, and the payment transaction dates. Print your name and title and sign where indicated. After you are approved, please notify us of any changes by completing a Waste Transporter Information Update form. This form can be obtained from the website identified above or by contacting us at the numbers below. QUESTIONS/NEED ASSISTANCE? Call us at (314) 436-8755, 436-8716 or 436-8784.