Pretreatment Service Request

Pretreatment Service Request
3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Requesting Area:

Other
Requestor Information:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Department
Email Address
example@example.com
Date of Request

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Request:
Other
Request Location Information:
Business Name
Type of Business
(i.e. restaurant, automotive, etc.)
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested date(s) for inspection:

*Please allow 24-hours from the date submitted to the requested inspection date. List your requested times in order of preference.
1st preferred date of inspection

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
2nd preferred date of inspection

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
3rd preferred date of inspection

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
Contact Name

First NameLast Name
Contact Title
Phone Number

Area CodePhone Number
SGRWRF Pretreatment Department Use Only
Is the facility in compliance
Follow-Up action required:
Findings and/or follow-up action required:
Inspector:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: