Liquid Waste Operator Permit Application
Date
-
Month
-
Day
Year
Date
Facility Name:
*
Facility Address (physical and mailing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Owner's Name
First Name
Last Name
Owner's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Email
example@example.com
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Pump Operators
All operators must be present during permit inspection. Only the operators listed below will be allowed to perform liquid waste operations. TriCounty Health Department must be notified of all operators.
LIST OF OPERATORS
*
COLLECTION VEHICLE INFORMATION
*
FACILITIES OR SITES FOR DISPOSAL OF WASTE
*
Fee
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( X )
Inspection Permit Fee
$
200.00
Credit Card
Applicant's Signature
Submit
Should be Empty: