Application for Dumping

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Application for Dumping
Application Date

MonthDayYear
Date
Contact Information
Name of Business*
Contact Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
1. Truck Make and Model:
Truck License No.:
Health Dept. Permit Number:
Renewal Date:

MonthDayYear
Date
2. Truck Make and Model:
Truck License No.:
Health Dept. Permit Number:
Renewal Date:

MonthDayYear
Date
*Use additional sheets if necessary.
Date:

MonthDayYear
Date
Full Name:

First NameLast Name
Signature

Clear
For SGRWRF use only
Approved:
SGRWRF Plant Manager
Date:

MonthDayYear
Date
Should be Empty:

Contact Information