Application For Waste Hauler Permit
ADVERTISEMENT
1
2COUNTY OF WASHINGTON, VIRGINIA
APPLICATION FOR WASTE HAULER PERMIT
BOARD OF SUPERVISORS
PLEASE SEE PAGE 2 OF THIS FORM FOR INSTRUCTIONS FOR COMPLETION
APPLICANT INFORMATION
APPLICATION FOR:
- NEW PERMIT
- RENEWAL OF PERMIT
APPLICANT NAME: _________________________________________________________________________________________________________________________
APPLICANT’S VIRGINIA STATE CORPORATION COMMISSION ID NO. (if applicable): __________________________________________________
APPLICANT’S BUSINESS HOME ADDRESS:
___________________________________________ _____________________________ ________ ____________ _________________________
Street Address or P.O. Box
City
State
Zip Code
Area Code & Office Telephone
APPLICANT’S BUSINESS HOME CONTACT PERSON: ____________________________________________________________________________________________
APPLICANT’S BUSINESS HOME PERSON E-MAIL: _______________________________________________________________________________________________
APPLICANT’S LOCAL OFFICE ADDRESS (if different than Business Home Address):
___________________________________________ _____________________________ ________ ____________ _________________________
Street Address or P.O. Box
City
State
Zip Code
Area Code & Office Telephone
__________________________ ___________________________________________________________________
Area Code & Fax Number
E-mail
APPLICANT’S LOCAL OFFICE CONTACT PERSON: ______________________________________________________________________________________________
APPLICANT’S LOCAL CONTACT PERSON E-MAIL: _______________________________________________________________________________________________
LOCAL OFFICE HOURS: _______AM to _______PM _____________________________________________________________________________________________
Days of Week of Local Office Hours - Local Office Hours must be minimum of 8 hours per day/3 days per week
APPLICANT’S TOLL-FREE CUSTOMER SERVICE TELEPHONE NUMBER (if no Local Office): ________________________
Area Code & Telephone No.
APPLICANT’S AGENT FOR SERVICE OF LEGAL PROCESS: _______________________________________________________________________________________
AGENT’S ADDRESS:
___________________________________________ _____________________________ ________ ____________ _________________________
Street Address or P.O. Box
City
State
Zip Code
Area Code & Office Telephone
__________________________ __________________________ ___________________________________________________________________
Area Code & Mobile Telephone
Area Code & Fax Number
E-mail
PERSON COMPLETING THIS APPLICATION: ____________________________________________________________________________________________________
MAILING ADDRESS OF ABOVE PERSON (if different than Corporate Office or Local Office Address):
___________________________________________ _____________________________ ________ ____________ _________________________
Street Address or P.O. Box
City
State
Zip Code
Area Code & Office Telephone
__________________________ __________________________ ___________________________________________________________________
Area Code & Mobile Telephone
Area Code & Fax Number
E-mail
METHOD OF SERVICE DELIVERY
PLEASE SELECT ONE OF THE FOLLOWING OPTIONS:
- OPTION #1 - APPLICANT AGREES TO PROVIDE COUNTYWIDE SERVICES AT UNIFORM COUNTYWIDE RATES AND HAS ATTACHED A RATE SCHEDULE
THAT APPLICANT WILL ADHERE TO WITHOUT VARIATION (ATTACHMENT 1).
- OPTION #2 - APPLICANT DOES NOT AGREE TO PROVIDE ALL SERVICES COUNTYWIDE AT UNIFORM COUNTY-WIDE RATES AND HAS ATTACHED A
DETAILED REQUEST FOR A VARIANCE PURSUANT TO CHAPTER 50, ARTICLE II, DIVISION 2 OF THE CODE OF THE COUNTY OF WASHINGTON, VIRGINIA
(2002) AND THE APPROPRIATE NON-REFUNDABLE FEE FOR A VARIANCE APPLICATION AND APPROPRIATE RATE SCHEDULES WHICH, IF APPROVED,
APPLICANT WILL ADHERE TO WITHOUT VARIATION (ATTACHMENT 2).
APPLICANT CERTIFICATION & SIGNATURE
THE UNDERSIGNED APPLICANT SHALL COMPLY WITH ALL APPLICABLE REQUIREMENTS OF CHAPTER 50 THE CODE OF THE COUNTY OF WASHINGTON,
VIRGINIA (2002) AND FURTHER AGREES TO THE FOLLOWING:
A.
TO ONLY USE WASTE HAULING VEHICLES IDENTIFIED IN ATTACHMENT 4 WITHIN WASHINGTON COUNTY, VIRGINIA;
B.
TO PROVIDE ALL REQUIRED CERTIFICATIONS OF COMPLIANCE, INSURANCE, BONDS AND LICENSES UPON ISSUANCE OF A WASTE HAULER
PERMIT;
C.
TO ABIDE BY APPLICANT’S FEE SCHEDULE AND PROVIDE ANY SERVICE LISTED IN THIS APPLICATION AT THE LISTED FEE TO ANYONE AT ANY
LOCATION WITHIN WASHINGTON COUNTY, VIRGINIA;
D.
TO DISPOSE OF SOLID WASTE AT FEDERAL, STATE AND\OR LOCALLY APPROVED SITES;
E.
TO TAKE ALL RECYCLABLES TO APPROVED FACILITIES, AND
F.
TO PROVIDE ALL REQUESTED RECORDS AND DOCUMENTATION ON THE AMOUNT OF SOLID WASTE AND\OR RECYCLABLES COLLECTED, THE
FACILITIES USED WITHIN WASHINGTON COUNTY, VIRGINIA AND THE FACILITIES THAT ULTIMATELY ACCEPTED THE SOLID WASTE AND\OR RECYCLABLES.
THE APPLICANT UNDERSTANDS THE WASHINGTON COUNTY, VIRGINIA BOARD OF SUPERVISORS MAY APPROVE THIS APPLICATION CONTINGENT UPON THE
APPLICANT SUBMITTING PROOF OF BOND AND INSURANCE, PAYMENT OF THE LICENSING FEE, AND\OR CORRECTION OF ANY OTHER DEFICIENCIES THAT
MAY EXIST AND THAT THE WASTE HAULER PERMIT WILL NOT BE ISSUED UNTIL REQUIREMENTS ARE MET.
_
APPLICANT SIGNATURE: ________________________________________________________________________________ DATE: __________________________
05-06
ADVERTISEMENT
0 votes
Related Articles
Related forms
Waste Hauler Permit Application For Collection And Transportation Of Solid Waste And Recyclable Materials In Putnam County
Business
Application For Special Parking Permit Or License Plates For A Physically Disabled Person Form 2000
Legal
Related Categories
Parent category: Business