Application for Dumping

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

Month Day Year
Date
Contact Information
Name of Business *
Contact Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

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

Month Day Year
Date
2. Truck Make and Model:
Truck License No.:
Health Dept. Permit Number:
Renewal Date:

Month Day Year
Date
*Use additional sheets if necessary.
Date:

Month Day Year
Date
Full Name:

First Name Last Name
Signature

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

Month Day Year
Date
Should be Empty:

Contact Information