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2. Permit Information
4. Permits are valid from July 1 through June 30 of the following year.
6. Permit Application Status:*

   1. New
   2. Renewal
10. Applicant Information
12. Name of Applicant:*
13. Company Name:*
15. Address:*
16. City:*
18. State:*
19. ZIP Code:*
21. Email:*
22. Phone Number:*
26. Vehicle / Tank Information
28. Vehicle License Number:*
29. Tank (Gallons):*
31. Vehicle License Number:
32. Tank (Gallons):
34. Vehicle License Number:
35. Tank (Gallons):
37. Vehicle License Number:
38. Tank (Gallons):
40. Vehicle License Number:
41. Tank (Gallons):
43. Vehicle License Number:
44. Tank (Gallons):
46. Vehicle License Number:
47. Tank (Gallons):
49. Vehicle License Number:
50. Tank (Gallons):
54. Septage Volume Information:
56. Estimated Annual Septage Volume of Discharge (Gallons)*
60. Certification & Indemnification Agreement
62. Indemnification Agreement*

    In consideration of being issued a septage hauler discharge permit by the City of Concord ("City"), Permittee agrees to defend, indemnify, and hold harmless the City and its officials, agents, and employees (collectively, the "Indemnified Parties") from and against all demands, claims, suits and actions seeking damages, penalties, attorney's fees, costs, expenses, equitable relief, statutory relief or any other relief on account of bodily injury, death, personal injury, property damage, economic injury and any other injury or loss, (collectively, "Liabilities") arising from or relating to this permit, unless the Indemnified Parties were solely negligent. The indemnification obligations set forth herein shall survive the term of the permit. Permittee must choose defense counsel acceptable to the City and obtain the City's consent to any proposed settlement.

    1. I agree
64. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you are duly authorized to agree to these terms and consent to this electronic submission.

    1. I agree
66. Electronic Signature of Owner or Authorized Agent*
67. Current Date & Time:*
    Current Date & Time:

    Current Date & Time:
69. Organization:*
70. Position Title*
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field