DEPARTMENT OF LICENSING AND CONSUMER AFFAIRS 
Water Hauler Price Survey 
 
 
Name of Business: _____________________________________________________________________ 
Mailing Address: _______________________________________________________________________ 
Physical Address:______________________________                     Cell:__________________________________ 
Tel: ____________________________________________                e-mail:_____________________________________ 
 
Legal Form of your Business (Corp., Partnership, LLC): _____________________________________ 
 
Total Number of Trucks: _____________________________ 
Truck Capacity: 
Truck 1: ____________________________  
  
 
 
Truck 2: ____________________________ 
 
 
 
Truck 3: ____________________________ 
 
 
 
 
Truck 4: ____________________________ 
 
Price Per Truck : 
Low: $________________________  to High: $______________________________ 
 
 
 
Low: $________________________  to High: $______________________________ 
Low: $________________________  to High: $______________________________ 
 
 
 
Low: $________________________  to High: $______________________________ 
Are there additional charges depending on Difficult & Dangerous locations? 
 
 
 
Yes: _____________________    No: ______________________ 
Are there additional charges depending on the amount of hoses required for delivery? 
 
 
 
Yes: _____________________    No: ______________________ 
Where is your water collected from? (Exp. WAPA)  
1.)  _____________________________________________ 
2.) ______________________________________________ 
3.) ______________________________________________ 
4.) ______________________________________________ 
 
I hereby certify that the information provide herein is true and correct. 
 
______________________________________          _______________________________                ________________ 
 
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