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Scavenger Waste Hauler Discharge Permit Form - Monroe County Department Of Environmental Services Page 3

TTACHMENT TO

ONROE

OUNTY

CAVENGER

ASTE

AULER

ISCHARGE

ERMIT

All data entered on this form is to be accurately reported and certified to be correct.

It is the permittee’s responsibility to certify the data on this sheet is correct. By signing the permit, the

permittee is certifying this information is accurate.

A. NYSDEC Part 364 Permit No.

Expiration Date

B. Vehicle

Vehicle Number

1. Make/Model

2. Year Built

3. Color

4. License

Plate Number

5. State Vehicle

Registered

6. Truck Type

7. Maximum

Tank Capacity

B-4—License plate numbers entered for tractor-trailers require the plate number for the trailer portion of the vehicle. The tractor

plate number is not required. Use one column for each trailer.

B-6—Enter the truck type as one of the following – Strait Body Tanker, Tractor-Trailer, Vactor, Pick-up Truck with Tank (PU

w/Tank), or Other.

B-7—Maximum tank capacity is the certified tank volume as designed and specified by the manufacturer. There shall be no

modification or exception to this volume.

Note: For additional vehicles and/or information, please attach a supplemental sheet and

check (√) here _____.

Scavenger Waste Hauler Discharge Permit Form - Monroe County Department Of Environmental Services Page 3