Non-Hazardous Liquid Waste Haulers License Application - Cheyenne Laramie County Public Health

Please check appropriate category:(Required)

Individual

Corporation

Firm

Fee:(Required)

New: $375

Renewal: $185

Name of Business:(Required)

Business Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Cell Phone Number:(Required)

If a corporation or firm, give the proper corporation/firm name, agent for service, and corporation/firm officers:

Name of Applicant:(Required)

First Last

Applicant Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Please provide proof of insurance:(Required)

Max. file size: 50 MB.

THE APPLICANT CERTIFIES THAT HE/SHE IS FULLY ACQUAINTED WITH THE LARAMIE COUNTY SMALL WASTEWATER SYSTEMS REGULATIONS, SECTION 17, AND WILL CONDUCT THE BUSINESS IN COMPLIANCE WITH THE REGULATIONS.

Applicant's Signature:(Required)

Draw your signature.

Date:(Required)

Please indicate your vehicle(s) “S” number(s):(Required)

Action by Health Authority:

Authority Signature:

Date: