Waste Hauler Permit Application For Collection And Transportation Of Solid Waste And Recyclable Materials In Putnam County Page 10

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Waste Hauler Permit Application for Collection and Transportation of
Solid Waste and Recyclable Materials in Putnam County
SECTION 5 - INTENT
Please describe, in detail the nature of the waste hauler services which applicant will provide upon
issuance of a permit:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SECTION 6 - Days and Hours of Operation:
(check all that apply and fill in times of operation, circle am/pm)
_____ Monday
from _________am/pm to __________am/pm
_____ Tuesday
from _________am/pm to __________am/pm
_____ Wednesday
from _________am/pm to __________am/pm
_____ Thursday
from _________am/pm to __________am/pm
______
Friday
from _________am/pm to __________am/pm
_____ Saturday
from _________am/pm to __________am/pm
_____ Sunday
from _________am/pm to __________am/pm
Do you adjust your schedule for holidays? (please explain)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
SECTION 7 – WORKERS COMPENSATION & DISABLITY
This is to certify, under the penalties of perjury, that this operation has Workers’ Compensation & Disability
Benefits coverage required by law: (Attach copies. ACORD Forms are NOT acceptable. Acceptable
forms are: U-26.3, C105.2 or the Certificate of Attestation of Exemption CE-200 – attachment 1)
Workers’ Compensation Carrier : __________________________________________________________
Workers’ Compensation Policy # : ______________________________Exp. Date: _________________
Disability Benefits Carrier : ______________________________________________________________
Disability Benefits Policy # : ___________________________________Exp. Date: _________________
-or-
Workers’ Compensation Board has endorsed Exemption Form CE-200 stating that such coverage is not
required. Follow directions to obtain Attestation of Exemption Form (Attach signed and dated copy)

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