Liquid Waste Operator

Please select ALL types of liquid waste services provided by the business entity:

Please fill out the following information for each liquid waste collection vehicle. The first vehicle
has a permit fee of $70. Any additional collection vehicles will be charged a permit fee of $35
each. Please use an additional form as needed.

Vehicle 1 ($70 Fee):

 
Vehicle 2 ($35 Fee):

 
Vehicle 3 ($35 Fee):

Vehicle 4 ($35 Fee):

 
Vehicle 5 ($35 Fee):

 
Vehicle 6 ($35 Fee):

Please select ALL of the applicable counties where collection, storage, or disposal of liquid waste occurs by the business entity:

In the following table, please list the name and address of all liquid waste disposal sites used:

Facility 1


 
Facility 2


 
Facility 3


 
Facility 4


 

A surety bond is currently considered optional. Please indicate below whether the business
entity listed in this application wishes to provide documentation of a surety bond:

If “YES” please attach surety bond documentation to this application.

Digital Signature

By typing your name below, you are signing this form electronically. You agree to, and understand, all the information you are submitting: