Application for Dumping

2176 W. Treatment Plant Rd., St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Application for Dumping
Type of Busines

Other
Company Name
Owner
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email Address
example@example.com
Physical Address (registered business address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vehicle/Equipment Information:
1. Make and Model:
License No.:
Health Dept. Permit Number:
Health Dept. Permit Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2. Make and Model:
License No.:
Health Dept. Permit Number:
Health Dept. Permit Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3. Make and Model:
License No.:
Health Dept. Permit Number:
Health Dept. Permit Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
*Use additional sheets if necessary.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name:

First NameLast Name
Signature
For SGRWRF use only
Approved:
SGRWRF Plant Manager
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The St. George Regional Water Reclamation Facility must approve this application before any dumping occurs. Upon request by the SGRWRF, all applicants are required to provide copies of their current Business License and Health Permit.
Should be Empty:

Vehicle/Equipment Information: