HomeMy Public PortalAboutC6 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.