GEORGIA ENVIRONMENTAL PROTECTION DIVISION COMMERCIAL TRANSPORTER REGISTRATION FORM

DIRECTIONS: THIS PAGE MUST BE FILLED OUT COMPLETELY. FAILURE TO PROVIDE ANY OF THE REQUIRED INFORMATION WILL RESULT IN YOUR APPLICATION NOT BEING ACCEPTED. YOU MUST ALSO LIST YOUR DISPOSAL LOCATION(S) FAILURE TO PROVIDE WILL RESULT IN YOUR APPLICATION NOT BEING ACCEPTED. ONCE YOU HAVE COMPLETED THE BRIEF QUESTIONNAIRE CLICK THE SUBMIT BUTTON TO SEND YOUR REGISTRATION ELECTRONICALLY TO THE GEORGIA ENVIRONMENTAL PROTECTION DIVISION. THE GEORGIA F.O.G ALLIANCE IS NOT RESPONSIBLE FOR YOUR REGISTRATION AND THE COMPLETION OF IT. THE INFORMATION YOU PROVIDE IS PUT IN A DATA BASE.

TODAY"S DATE:

Date

COMPANY INFORMATION: (* THIS INFORMATION IS REQUIRED TO OBTAIN YOUR FOG PERMIT NUMBER)

COMPANY NAME:

CONTACT PERSON:

JOB TITLE:

PHYSICAL ADDRESS:

MAILING ADDRESS

CITY:

STATE:

ZIP CODE:

BUSINESS PHONE:

CONTACT PERSON PHONE:

BUSINESS FAX:

CONTACT E-MAIL:

COMPANY WEBSITE:

TOTAL YEARS IN BUSINESS:

TOTAL NUMBER OF TRUCKS YOU WISH TO REGISTER:

HOW DOES YOUR BUSINESS SERVICE CUSTOMERS? (EXAMPLE: CONTRACT, SCHEDULED TIMES, CALL WHEN NEEDED)

PLEASE SELECT THE TYPES OF TRAPS OR INTERCEPTORS THAT YOUR COMPANY SERVICES FOR ITS CUSTOMERS: (PLEASE SELECT ALL THAT APPLY)

GEORGIA IS BROKEN UP INTO REGIONS. PLEASE USE THE MAP ABOVE TO LET US KNOW WHAT IS YOUR SERVICE AREA.

COMMERCIAL WASTE PERMIT INFORMATION:

PLEASE LET US KNOW THE TYPES OF PERMITS YOUR COMPANY HAS:(EXAMPLE: NPDES, LAS, INDUSTRIAL PRETREATMENT BY DIVISION OR INDUSTRIAL PRETREATMENT BY AUTHORITY)

TYPE OF COMMERCIAL WASTE PERMIT:

PERMIT NUMBER:

ISSUED BY:

TYPE OF COMMERCIAL WASTE PERMIT:

PERMIT NUMBER:

ISSUED BY:

F.O.G PERMIT INFORMATION:

HAS YOUR COMPANY REGISTERED WITH THE STATE OF GEORGIA FOR A FOG PERMIT BEFORE?

IF YES, PROVIDE FOG NUMBER:

HAS YOUR COMPANY CHANGED NAMES OR OWNERS?

IF YES, PROVIDE NEW NAME;

DO YOU WISH TO KEEP YOUR EXISTING FOG NUMBER?

DOES YOUR COMPANY TRANSPORT COMMERCIAL WASTE ACROSS STATE LINES?

IF YES, PROVIDE THE LOCATION INFORMATION: (NAME, ADDRESS, PHONE)

DOES YOUR COMPANY HANDLE SEPTAGE WASTE?

DPH SEPTAGE REMOVAL PERMIT #:

COUNTY REGISTERED WITH:

DISPOSAL LOCATION INFORMATION: (YOU MUST ENTER INPUT A DISPOSAL LOCATION OR YOUR PERMIT WILL NOT BE ACCEPTED)

DISPOSAL LOCATION #1:

ADDRESS INFORMATION LOCATION #1: (PLEASE INPUT ADDRESS, CITY, STATE & ZIP)

DISPOSAL LOCATION #1 PHONE NUMBER:

DISPOSAL LOCATION #2:

ADDRESS INFORMATION LOCATION #2: (PLEASE INPUT ADDRESS, CITY, STATE & ZIP)

DISPOSAL LOCATION #2 PHONE NUMBER:

DISPOSAL LOCATION #3:

ADDRESS INFORMATION LOCATION #3: (PLEASE INPUT ADDRESS, CITY, STATE & ZIP)

DISPOSAL LOCATION #3 PHONE NUMBER:

I CERTIFY THAT THIS DOCUMENT WAS PREPARED UNDER MY DIRECTION OR SUPERVISION IN ACCORDANCE WITH THE SYSTEM DESIGNED TO ASSURE THAT QUALIFIED PERSONNEL PROPERLY GATHER AND EVALUATE THE INFORMATION SUBMITTED. THE INFORMATINO PROVIDED IS TO THE BEST OF MY KNOWLEDGE AND BELIEF TO BE TRUE, ACCURATE, AND COMPLETE. I ALSO AGREE TO ALLOW THE GEORGIA ENVIRONMENTAL PROTECTION DIVISION TO USE THE INFORMATION PROVIDED TO ISSUE ME A FOG PERMIT NUMBER FOR THE STATE OF GEORGIA. I UNDERSTAND THAT THIS DOES NOT COMPLETE MY PERMIT PROCESS AND THAT IN ORDER TO BE COMPLIANT IN THE STATE OF GEORGIA I MUST HAVE MY SERVICE TRUCKS INSPECTED.

DIGITAL SIGNATURE:

DATE SIGNED:

Date

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