Wastewater Hauler/Insurance Registration Form

• This form is common to each Hauler and is entered one time to advise of the following:
  • Business Name
  • Business Owner
  • Regular and Emergency Contact Information
  • NJDEP Registration
  • Insurance
    • Company
    • Policy #
    • Expiration

Business Name
Business Street
Business City
Business State
Business Zip
Business Phone
Business Email
Owner's Name
Owner's Phone
Owner's Email
ACUA Account #
NJDEP Registration #
Insurance Name
Insurance Policy #
Insurance Policy Expiration