COLLECTION AND TRANSPORT RECORDS FORM

Sample Form to be filled by Licensee i. Identification of Waste: a) Volume b) Type:__________ Septic Tank______________Others c) Address ii. Details of Waste Generator: a) Name b) Phone Number c) Address d) Pin The undersigned being duly authorized does hereby certify the accuracy of the source and type of wastewater collected. Date___________________Signature of septage generator iii. Details of Transporter/Operator: a) Company Name b) Permit No. c) Vehicle License d) Pump out date The above described wastewater was collected and disposed by me to the disposal facility name below and was discharged. I certify that the foregoing is true and correct. e) Signature of authorized agent and title:____________________________ iv. Acceptance by__________________DJB’s authorized SPS/STP The above transporter delivered the described septage to this disposal facility and it was accepted. Disposal Date_______________Amount Collected from Transporter________ Signature of authorized signatory and title___________________________ NOTE: SUBJECT TO THE TERMS AND CONDITIONS OF DELHI WATER BOARD SEPTIC TANK WASTE MANAGEMENT REGULATIONS 2015 AND ORDERS/GUIDELINES ISSUED BY THE BOARD UNDER THESE REGULATIONS FROM TIME TO TIME.