Fillable Waste Hauler Registration PDF (City of Bedford)

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Waste Hauler Registration PDF (City of Bedford)

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The Waste Hauler Registration PDF (City of Bedford) form is 2 pages long and contains:

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  • 12 check-boxes
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File type: PDF

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City of Bedford
Public Works Department
1813 Reliance Pkwy
Bedford, TX 76021
Phone 817-952-2200 Fax 817-952-2240
WASTE HAULER REGISTRATION
Registration Fee: $240 first vehicle, $130 each additional
Permit Period: Jan 1 to Dec 31
**TRANSPORTERS ARE REQUIRED TO USE TRIP TICKETS ISSUED BY THE CITY OF BEDFORD**
Business Name
TCEQ Registration No.
Physical Address
DOT#
City Zip
Name of Owner/Parent Corp.
Mailing Address
Name of Operations Manager
City Zip
Business Phone Fax
Email
ATTACH PHOTOCOPY OF OPERATOR’S DRIVER LICENSE
PROVIDE THE FOLLOWING SPECIFIC INFORMATION ON EACH VEHICLE TO BE PERMITTED
Vehicle
Permit No.
Year Make
Tank
Capacity
(Gallons)
License Plate
Number
Inspected &
Approved by
Fee Amount
INDICATE LIQUID WASTE TO BE TRANSPORTED
GREASE
GRIT
SEPTIC
CHEMICAL TOILET
I, the undersigned, hereby make application to transport liquid waste in the City of Bedford, Texas, and declare to
accept and abide by all pertinent ordinances and regulations in the City of Bedford, Texas. I understand that
falsification of any information submitted in the application shall be cause for termination of the liquid waste
transportation permit, and that each permit shall be renewed on an annual basis.
Date Signature of Owner/Manager
TO BE FILLED OUT BY WASTEWATER SUPERVISOR (If Inspection Required)
YES
NO
BUSINESS NAME & PERMIT NO. PERMANENTLY INSTALLED IN CONTRASTING COLOR
VEHICLE CLEAN & ODOR FREE
VEHICLE EQUIPPED FOR SAFE OPERATION (INSPECTOR’S DISCRETION)
PIPING, VALVES & CONNECTORS PERMANENTLY ATTACHED TO TANK OR VEHICLE
ALL EQUIPMENT LIQUID TIGHT
ALL EQUIPMENT SUITABLE FOR TYPE & AMOUNT OF WASTE HANDLED
SAFETY PLUG OR CAP FOR EACH VALVE
Submittal of Application and Method of Payment
I have read the completed application and know the same is true and correct and hereby agree that if a permit is issued all
provisions of the City Ordinances and State Laws will be complied with whether herein specified or not. I agree to comply with
all property restrictions. I am the owner of the property or the duly authorized agent.
Submit application and pay by cash, check or credit card in person.
One time charge on my credit card. Application by fax, mail or email. (credit card payment form attached)
Charge my credit card on file. Application by fax, mail or email. (last four digits of account #)
Application and payment by phone. (only with credit card information on file)
completed and approved by the Building Official. Applicants will be notified when this process is complete. Applicants
Applicant Name (Print)
Applicant Signature
Date
COB-PW Office Use Only
Approved
Date
Denied
Office Use Only
Permit Number:
City of Bedford
Public Works Department
1813 Reliance Pkwy
Bedford, TX 76021
Ph: (817) 952-2200 Fax: (817) 952-2240
Email: pw.permits@bedfordtx.gov
Credit Card Payment Form
Instructions for Completing the Credit Card Payment Form
• Enter all credit card information including the payment amount to be charged to your credit card and remember to sign the
form. The City of Bedford cannot process an incomplete form or process credit card payments without an authorized
signature.
• The City of Bedford does not accept debit cards or check cards that require use of a personal identification number as a
method of payment.
• Address information is required for credit card payment as a means of verification. Failure to complete the address
information may result in the payment not being accepted by your credit card institution.
• The City of Bedford requires using this form for credit card payments submitted by mail, facsimile, or email. To protect your
credit card information, use only this form.
• Credit Card Information must include the 3 digit security code on the back of the credit card: example:
• If the cardholder includes a credit card number on any form or document other than the Credit Card Payment Form or
submits this form electronically via fax or email, the City of Bedford will not be liable in the event that the credit card
number becomes public knowledge.
• This PDF file contains form fields allowing you to type in your pertinent information. Once filled out, it can be printed out
and faxed to 817-952-2240, scanned and emailed to
pw.permits@bedfordtx.gov or mailed to City of Bedford, Attn:
Public Works Permits Processing, 1813 Reliance Pkwy, Bedford TX 76021. Please note for additional security purposes this
PDF file will not allow a filled out form to be saved, only printed.
Credit Card Information
Credit Card Type: Visa MasterCard
Credit Card Account #:
Expiration Date:
(mm/yy)
3 Digit Code:
(on back of card)
Name as it Appears on Card
Payment Amount: $
(US Dollars)
Credit Card Billing Address
Street Address 1:
Street Address 2:
City:
State:
Zip:
Daytime Phone:
Fax:
Email Address:
Payment Information
Describe Purpose of Payment:
I authorize The City of Bedford to keep this information on file for future use.
I do not authorize The City of Bedford to keep this information on file for future use. Please use for the current transaction
only.
I authorize The City of Bedford to charge my credit card account for payment of permits, inspections, contractor registration or
any associated fees with the City of Bedford and to verify the billing address of my Credit Card with the issuing bank upon my
signature. If The City of Bedford is unable to process my payment, I will be responsible for an alternate payment arrangement
and any penalty fee which results. By signing this authorization, I acknowledge that I have read and agree to all of the above.
All information given is complete and accurate.
Card Holders (signature):
Date:
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Waste Hauler Registration PDF (City of Bedford)

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Completed 14 July 2020

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