Form Eht05 - Registration Of Portable Toilet Facilities July 2015 printable pdf download

Form Eht05 - Registration Of Portable Toilet Facilities July 2015

C o u n t y o f F a i r f a x , V i r g i n i a

To protect and enrich the quality of life for the people, neighborhoods and diverse communities of Fairfax County

APPLICATION FOR REGISTRATION OF PORTABLE TOILET FACILITIES

OWNER'S NAME: ________________________________________________________

COMPANY NAME: _______________________________________________________

ADDRESS: _______________________________________________________________

CITY, STATE, ZIP: ___________________________________ PHONE:____________

FAX # __________________ EMAIL ADDRESS: _______________________________

Does hereby apply for annual registration to provide Portable Toilets in Fairfax County, Virginia and will perform all work in

accordance with the requirements of Chapter 68.1 of the Fairfax County Code and the Commonwealth of Virginia, State Board

of Health, Sewage Handling and Disposal Regulations.

SIGNED: _____________________________________

PLEASE PRINT NAME: _________________________________________

FEDERAL TAX ID # ____________________________________________

DO YOU PROVIDE PORTABLE TOILET FACILITIES ONLY:

YES/NO

DO YOU SERVICE THE PORTABLE TOILET FACILITIES YOU PROVIDE:

YES/NO

IF NO: DO YOU CONTRACT FOR SERVICE:

YES/NO

DO YOU USE MORE THAN ONE (1) SEWAGE HANDLING CONTRACTOR:

YES/NO

IF SO WHOM: 1.______________________________________________________________

2.______________________________________________________________

FOR HEALTH DEPARTMENT USE ONLY

REGISTRATION YEAR: _______ #: _____-PT-_________

_ EXPIRES: 12/31/________________

Index Code:

713107

NEW REGISTRATION $_________________

Sub-object Code

0472

RENEWAL REGISTRATION $____________

APPLICATION APPROVED BY: ______________________________ DATE: _____________

EALTH DEPARTMENT OFFICIAL

____________________________________ has registered as requested under Chapter 68.1 of the

Fairfax County Code. LIMITED TO: PROVIDING & MAINTAINING PORTABLE TOILETS OR

SIMILAR DEVICES FOR HOLDING SEWAGE WASTE.

_______________________________________________________________________________________

Fairfax County Health Department

Division of Environmental Health

Technical Review and Information Resources

10777 Main Street, Suite 102, Fairfax, VA 22030

Phone: 703-246-2201 TTY: 711 Fax: 703-653-9448

EHT05 REV. 7-15

Form Eht05 - Registration Of Portable Toilet Facilities July 2015

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