Fillable Maricopa County Environmental Services Department PERMIT APPLICATION FOR (Maricopa County Telecommunications)

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Maricopa County Environmental Services Department PERMIT APPLICATION FOR (Maricopa County Telecommunications)

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Maricopa County Environmental Services Department
Water and Waste Division
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Phone: 602-506-6666 Email: WWM_SWP@mail.maricopa.gov Fax:602-506-6925
(R October 12, 2018)
PERMIT APPLICATION FOR WATER & WASTE COMPLIANCE PERMITS
PERMIT INFORMATION
Company Name:
Permitted Item’s Address/Storage Location Address:
City:
State:
Zip Code:
OWNER INFORMATION
Organization Name (LLC, Inc., Sole Proprietor Name):
Owner’s Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
BILLING INFORMATION Same As: Owner
Contact Organization Name:
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
INSPECTION CONTACT INFORMATION Same As: Owner Billing
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
MAILING INFORMATION Same As: Owner Billing
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
*******THIS SECTION FOR REFUSE COLLECTION VARIANCE OR NHLW TRANSFER FACILITY*******
LICENSED PROFESSIONAL Not Applicable-Project Constructed Value less than $12,500
Contact Organization Name:
AZ License #
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
AUTHORIZED AGENT Same As: Business/Project Owner Licensed Professional
Contact Organization Name:
AZ License #
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
PROJECT INSTALLER Same As: Business/Project Owner Licensed Professional Authorized Agent
Contact Organization Name:
AZ License #
Contact Name:
Email:
Address:
City:
State:
Zip Code:
Phone No.:
Cell No:
Fax No.:
Maricopa County Environmental Services Department
Water and Waste Division
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Phone: 602-506-6666 Email: WWM_SWP@mail.maricopa.gov Fax:602-506-6925
(R October 12, 2018)
Office
Use Only
Permit #:
________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
Permit #:
________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
Permit #:
_________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
Permit #:
_________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
Permit #:
_________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
Permit #:
_________
VEHICLE
TRAILER
CONTAINER
Vehicle/Trailer No.:
Year:
License Plate State:
Make:
License Plate Number:
Type:
VIN/Identification No.:
Disposal Site:
ADEQ Registration No.:
Tank Capacity:
Tank Serial No:
Tank Bottom Drain:
YES NO
PERMIT SPECIFIC INFORMATION
TYPE OF APPLICATION:
NON-HAZARDOUS SOLID WASTE HAULER (REFUSE HAULER)
NON-HAZARDOUS LIQUID WASTE HAULER
BIO-HAZARDOUS MEDICAL WASTE HAULER
POTABLE WATER HAULER
LANDFILL
MOBILE HOME PARK
NHLW TRANSFER FACILITY
REFUSE COLLECTION VARIANCE
(SKIP THIS PAGE, GO TO PAGE 3)
Maricopa County Environmental Services Department
Water and Waste Division
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Phone: 602-506-6666 Email: WWM_SWP@mail.maricopa.gov Fax:602-506-6925
(R October 12, 2018)
PORTABLE RESTROOM UNIT OR WASTE HOLDING TANK
Office Use Only
Permit #:
_______________
Number of Units Type of Units/Description
MOBILE HOME PARKS
Office Use Only
Permit #:
_______________
Number of Spaces: Water type:
INDIVIDUAL WATER SYSTEM (WELL)
PUBLIC WATER SYSTEM
Number of Independents: Sewer type:
ISDS (SEPTIC)
PUBLIC SEWER SYSTEM
Number of Travel: POOL
SPA
QUANTITY: POOL SPA
OFFICE USE ONLY
Application Fees (Fees are subject to change)
Type
Application Fee
Total
ATC for Non-Hazardous Liquid Waste Transfer Facility
$150 STANDARD $300 EXPEDITE
Plan Review for Refuse Collection Frequency Variance
$150 STANDARD $300 EXPEDITE
For Internal Use Only
Amount Invoiced/Paid: $
Submittal Date:
Assigned District:
Site Location:
This establishment must demonstrate sufficient compliance to proceed with the issuance of the permit(s). To complete the issuance of each
permit and begin operation, the applicant must first submit payment of the permit fee to the Department’s Business Services Office. Per
Chapter I, Regulation 4, of the Maricopa County Environmental Health Code, no person shall conduct an operation or an establishment
for which a permit is required without holding the necessary and valid permit to do so.
For reference, the following is a list of the annual prices for permits (R 6-23-2010):
• Mobile Home Park $200
• Landfill $450
• Refuse Hauler (Non-Hazardous Solid Waste Hauler) $120 per vehicle
• Non-Hazardous Liquid Waste Hauler $175 per vehicle
• Bio-Hazardous Medical Waste Hauler $200 per vehicle
• Drinking Water Hauler $240 per vehicle
• Portable Restroom Unit or Waste Holding Tank (see table)
APPLICANT SIGNATURE
Pursuant to A.R.S. § 41-1009, the Department may enter your establishment to conduct inspections. You have the right to receive a copy of the Department’s
inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise provided by federal law. By initialing below, I
agree that the Department may send me a copy of its inspection report by e-mail to the following email address:
or by facsimile transmission to the following fax number:
(Permit Owner/Holder) Initials:
It is the responsibility of the permit holder to update the Department if there is a change in
contact information.
I, the undersigned, do hereby agree to assume complete responsibility for full compliance with all applicable statutes, rules and regulations for the work
requested. The undersigned hereby requests that MCESD/Water and Waste Management Division conduct the appropriate review for the item listed on the
application and supplies the undersigned with the associated results. All notifications of completed procedures or other written correspondence will be
delivered in person, by mail or in electronic form. Per Maricopa County Environmental Health Code, this application will expire one year from date of
application unless renewed.
Signature:_______________________________________________________________ Date:_____________________________________
1-99 units
$5
350-499 units
$1,500
100-199 units
$550
500-999 units
$2,500
200-349 units
$1000
1000-1499 units
$4,500
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Maricopa County Environmental Services Department PERMIT APPLICATION FOR (Maricopa County Telecommunications)

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Completed 6 August 2020

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