"Bulk Water Hauling License Application Form" - Connecticut

Bulk Water Hauling License Application Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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Download "Bulk Water Hauling License Application Form" - Connecticut

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Connecticut Department of Public Health
Drinking Water Section
APPLICATION: BULK WATER HAULING LICENSE
APPLICANT’S CONTACT INFORMATION
Last Name
M. Initial
First Name
Company Name Applying For License (Corporation or Partnership or Sole Proprietor)
Names and Addresses of all officers of the Corporation or members of the Partnership, including name of General
Partner (Attach Separate Sheet of paper as necessary)
Address Line 1 (St. Address or P.O. Box #)
City
ST
Zip
Address Line 2 (Apt. #, Suite #, Box # - can be left blank)
City
ST
Zip
City
ST
ZIP
Business Address where vehicles stored if different from Above
Agent of Service Address for the Corporation or Partnership
City
ST
ZIP
Email
Telephone
Fax
Cell Phone
State Business Identification Number
Employer Identification Number (EIN)
Approved Source of Drinking Water from
Public Water Supply Identification Number (PWSID)
Which the Water to be hauled is Drawn:
Attach a Copy of the Company’s Technical Methods and Standard Operating Procedures for maintaining good Sanitary
Practices to the Application:
(See DPH Links for Bulk Water Hauling Guidelines and the Bulk Water Hauling Notification Form Below)
http://www.ct.gov/dph/lib/dph/drinking_water/pdf/Bulk_Water_Hauling_Guidelines.pdf
http://www.ct.gov/dph/lib/dph/drinking_water/pdf/Bulk_Water_Hauling_Notification_Form.pdf
List the Motor Vehicles utilized for Bulk Water Hauling (Attach Separate Sheet of paper as necessary)
Cab
State of
Type of Tank
Volume
Vehicle (Cab) and
(C)
Connecticut
Location Where
(Stainless
Pumper
History of
(Capacity in
Tanker
Tanker Identification
License Plate
Equipment Stored
Steel, (ss)
Available
Tankers
gals) of
Age
Number VIN
Tanker
Number
Bare Steel,
And Size
prior Use
Tanker
(T)
(bs) etc.)
Page | 1
Connecticut Department of Public Health
Drinking Water Section
APPLICATION: BULK WATER HAULING LICENSE
APPLICANT’S CONTACT INFORMATION
Last Name
M. Initial
First Name
Company Name Applying For License (Corporation or Partnership or Sole Proprietor)
Names and Addresses of all officers of the Corporation or members of the Partnership, including name of General
Partner (Attach Separate Sheet of paper as necessary)
Address Line 1 (St. Address or P.O. Box #)
City
ST
Zip
Address Line 2 (Apt. #, Suite #, Box # - can be left blank)
City
ST
Zip
City
ST
ZIP
Business Address where vehicles stored if different from Above
Agent of Service Address for the Corporation or Partnership
City
ST
ZIP
Email
Telephone
Fax
Cell Phone
State Business Identification Number
Employer Identification Number (EIN)
Approved Source of Drinking Water from
Public Water Supply Identification Number (PWSID)
Which the Water to be hauled is Drawn:
Attach a Copy of the Company’s Technical Methods and Standard Operating Procedures for maintaining good Sanitary
Practices to the Application:
(See DPH Links for Bulk Water Hauling Guidelines and the Bulk Water Hauling Notification Form Below)
http://www.ct.gov/dph/lib/dph/drinking_water/pdf/Bulk_Water_Hauling_Guidelines.pdf
http://www.ct.gov/dph/lib/dph/drinking_water/pdf/Bulk_Water_Hauling_Notification_Form.pdf
List the Motor Vehicles utilized for Bulk Water Hauling (Attach Separate Sheet of paper as necessary)
Cab
State of
Type of Tank
Volume
Vehicle (Cab) and
(C)
Connecticut
Location Where
(Stainless
Pumper
History of
(Capacity in
Tanker
Tanker Identification
License Plate
Equipment Stored
Steel, (ss)
Available
Tankers
gals) of
Age
Number VIN
Tanker
Number
Bare Steel,
And Size
prior Use
Tanker
(T)
(bs) etc.)
Page | 1
Connecticut Department of Public Health
Drinking Water Section
Cab
State of
Type of Tank
Volume
Vehicle (Cab) and
(C)
Connecticut
Location Where
(Stainless
Pumper
History of
(Capacity in
Tanker
Tanker Identification
License Plate
Equipment Stored
Steel, (ss)
Available
Tankers
gals) of
Age
Number VIN
Tanker
Number
Bare Steel,
And Size
prior Use
Tanker
(T)
(bs) etc.)
**** A list of the names of the Individuals operating the vehicles noted above that were trained by the applicant must be
retained by the applicant and be made available upon request.
APPLICANT’S STATEMENT OF CERTIFICATION:
I certify that the information that I have provided in this application is correct and I understand that any deceptive or
fraudulent information is grounds for suspension, revocation, or any other disciplinary action set forth in section
19a-17 and 53a-157b of the Connecticut General Statutes. Applicant further agrees to comply with the bulk water hauling
regulations effective upon adoption, including the periodic inspection of equipment as deemed necessary by the
department.
Applicant’s Printed Name
Applicant’s Signature
Date signed
License Number
Authorized Signature
Date signed
For DPH Use Only
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