Golden Hills Self-Haul Waiver Application "*" indicates required fieldsStep 1 of 40%Customer/Business Name*Phone Number*Email Address* Enter Email Confirm Email Property Type* Single Family Home Apartment BusinessService Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Mailing Address Different?* Yes NoMailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Self-hauling is transporting your waste (In this case, organic waste and/or recyclable materials) off your property yourself instead of using J. Torres Co., Inc. collection services. Self-hauling also includes business back-hauling, when a business transports organic waste and/or recyclable materials to a destination owned and operated by the business using the business's own employees and equipment. Per State Law and GHCSD Ordinance, customers that wish to self-haul their recyclable and/or organic waste must ensure that recyclables and organic wastes are kept out of the landfill. Self-haulers are encouraged to sort the materials onsite and then bring them to the appropriate recycling facility or compost facility (as applicable) per SB 1383.Instead of using J Torres Co. Inc. collection services, this property is requesting to self-haul these materials:* Paper - Blue Recycling Can Cardboard - Blue Recycling Can Comingled recyclables (glass, plastic, metal tin cans) - Blue Recycling Can Organic waste (landscape trimmings, food scraps and food soiled paper) - Green Organics CanCheck all that applyWill the materials be sorted on your property?* Yes NoComplete this section if the material WILL be sorted on your propertyThe following materials will be sorted on-site (Choose all that apply):* Paper Plastics Cardboard Glass Metals OrganicsCheck all that applyRECYCLABLE materials will be brought to : Metropolitan Recycling 2601 S. Mt Vernon Bakersfield, Ca. 93304 OtherIf OTHER, list the facility name and addressORGANIC materials will be brought to : Tehachapi Landfill 12001 E. Tehachapi Blvd. Tehachapi, Ca. 93561 Bena Landfill 2951 Neumarkel Rd. Bakersfield, Ca.93307 Mojave Landfill 400 Silver Queen Rd. Mojave, Ca. 93501 OtherIf OTHER, list the facility name and addressComplete this section if the material will NOT be sorted on your propertyThe following materials will be brought to a High Diversion Recycling Facility or an Organic Waste Processing Facility as defined by SB 1383* Paper Plastics Cardboard Glass Metals OrganicsCheck all that applyHigh Diversion Recycling or Organic Waste Facility name and address:High Diversion Organic Waste Diversion Facility is defined as a facility that is in compliance with the reporting requirements of 14CCR 18815.5(d) and meets or exceeds an annual average Mixed Organic content Recovery rate of 50% January 1, 2022 and December 4, 2024 and 75% after January1, 2025, as calculated pursuant to CCR Section 18815.5(e) for Organic Waste received from mixed waste organic collection stream. Self Haul Requirements:Per State law SB1383 and Golden Hills Ordinance, customers that wish to self-haul must ensure that recyclables and organic wastes are kept out of the landfill. Customers are encouraged to sort the materials onsite and bring them to the appropriate recycling facility or compost facility.Business's that are approved to self-haul must keep a record of the amount of recyclable materials and organic waste delivered to each recycling facility or composting facility. The record shall be subject to inspection by Cal Recycle. The permit shall be filled out annually to HCSD/Designee no later than February 1st of each year as part of the conditions of approval. The records shall include the following information:Delivery receipts and weight tickets from entity accepting waste.The amount of material in cubic yards or tons transported by the Generator to each entity.If the material is transported to an entity that does not have scales on site, or employs scales capable of weighing the Self-Hauler's vehicle in a manner that allows it to determine the weight of materials received, the Self-hauler is not required to record the weight of material but shall keep a record of the entities that received the Organic Waste.** If GHCSD obtains information at any time that a resident approved to self-haul recyclables and/or organic wastes is not keeping these materials out of the trash , GHCSD shall revoke the Self-Haul Permit and direct J. Torres Co., Inc. to provide recycling and/or organic service. Violations of the Self-Haul Permit may be subject to fines. **** Customers that have been granted Self-Haul Permits must resubmit an application for a new waiver every year per State law. **Acknowledgement* I have read the Self Haul Requirements. Consent* I attest under that all of the following statements are true.I am authorized to sign this form and acknowledge that I have read and agree to the Self-Haul Permit requirements listed above.I attest that all information presented herein to be true and accurate and that recyclable or organic waste materials generated at this property will not be landfilled if this self-haul request is approved.I understand that approved Self-Haul Permits expire after one year after the signature date below and upon the property changing ownership, at which this property will need to submit a new waiver request or J Torres Co. Inc. will be delivering recycling and/or organic waste carts to this property.I acknowledge that GHCSD and J. Torres Co. Inc. will perform occasional inspections of waste carts to ensure that waste diversion is still occurring and if a significant amount of recyclables and/or organics are found in the trash, the Self-Haul Permit will be cancelled and J. Torres co. Inc. will provide recycling and organic service to include all necessary carts to this property for the then current monthly rate.Signature*Name* First Last TitleDate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameThis field is for validation purposes and should be left unchanged.