TE 5 2025-2026-WW-Pumper-Hauler-Application-Form.pdf

Before completing this application form, please read the “Guidelines for Wastewater and Wastewater Sludge

Pumpers and Haulers Registration” that can be found on the DOH-Wastewater Branch’s website.

1. COMPANY INFORMATION

Company Name: __________________________________________________________________

Contact Person & Title: ___________________________________________________________

Contact Person’s Email: ___________________________________________________________

)Fax No.: _ (___ )Phone No.: _ (_ _______________ ______ __ _________________

2. LOCATION

Island (Select one): Oahu

Maui

Kauai

Molokai

Big Island

Lanai

ADDRESS

Mailing Address: _________________________________________________________________

City, State, & Zip Code: ___________________________________________________________

Physical Address of Operation

(P.O. Box not allowed): ___________________________________________________________

City, State, & Zip Code: ___________________________________________________________

3. OWNERSHIP TYPE

(Select one): County

Private

State

Non-profit

Federal

Other:

If ‘Other’ is checked, specify type below:

For Official Use Only

Date Received:

Registration No:

Check No:

2025-2026 REGISTRATION FOR

WASTEWATER AND

WASTEWATER SLUDGE

PUMPERS AND HAULERS

4. ACTIVITIES CONDUCTED BY APPLICANT

Indicate all the activities conducted:

Cesspool/Septic Tank Pumping

Grease Trap Pumping

Hauling Sludge from Wastewater

Treatment Plant

Sewer Interceptor Pumping

Portable Toilet Pumping

Other: _____________________________

5. VEHICLE INFORMATION

List of license plates, vehicle descriptions, and the type of waste the vehicle will pump or haul (as indicated in #4-ACTIVITIES CONDUCTED BY APPLICANT) for all vehicles used to haul wastewater or wastewater sludge. If necessary, you may attach a separate sheet to your application that includes the required vehicle information below.

License

Plate Make Year/Model Color

Tank Size

(gal)

Type of Waste to be

Pumped/Hauled

6. CERTIFICATION

I certify that for a federal public agency, I am a principal executive officer of the agency, or I am the senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency.

I certify that for a state agency, I am a principal executive officer or ranking elected official.

I certify that for a corporation, I am the Manager of one or more manufacturing, production, or operating facilities an authorized to make management decisions which govern the operation of the regulated facility or facilities including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations. I can ensure that the necessary systems are established, or actions taken to gather complete and accurate information for permit application requirements and authority to sign documents has been assigned or delegated to me in accordance with corporate procedures.

Indicate one of the following:

I certify that for a limited liability company (LLC), I am the Manager or Member authorized to make management decisions for the LLC and in charge of a principal business function, or I perform similar policy or decision-making functions for the LLC

I certify that I am a general partner for a partnership.

I certify that I am the proprietor for a sole proprietorship.

I certify that for a corporation, I am the President, Vice President, Secretary, or Treasurer of the corporation and in charge of the principal business function, or I perform similar policy or decision-making functions for the corporation.

I certify that for a municipal agency, I am a principal executive officer or ranking elected official.

I certify that for a non-profit entity, I am the Manager or Member authorized to make management decisions.

I certify that for a trust, I am a trustee.

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I also certify that I have read, understand, and will follow all applicable rules regarding the collection, disposal, monitoring, and record keeping of pumping and hauling wastewater and wastewater sludge, including septage from individual wastewater systems and other wastewater systems.

I will assure that all federal, state, and local laws applicable to pumping and hauling activities are complied with; including but not limited to permitting, licensing and registration requirements. As the owner or owner’s representative, I will continue to provide employees of our pumping and hauling firm with adequate training in proper pumping, collection, hauling, and disposal of wastewater and wastewater sludge. I understand that upon request, I must submit any other information necessary to assess the wastewater and/or wastewater sludge use or disposal practices at my facilities. I acknowledge that failure to meet the above conditions may lead to suspension and/or revocation of this registration.

Signature: _______________________________________ Date: _______________________

Printed Name & Title: ________________________________________________________________

Company/Organization Name: ________________________________________________________

7. FEES AND PAYMENTS

$30 for new operations

$10 for renewal of an existing registered operation – if postmarked by November 15, 2024 $15 for renewal of an existing registered operation – if postmarked after November 15, 2024 and before February 13, 2025

Existing operations who do not submit a renewal application by February 13, 2025 must register as new operation.

Application fees should be made payable to STATE OF HAWAII

Note: Only checks or money orders will be accepted. No Cash.

8. SUBMITTAL

SEND COMPLETED FORMS AND THE APPROPRIATE APPLICATION FEE TO:

State of Hawaii Wastewater Branch 2827 Waimano Home Road #207 Pearl City, HI 96782