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Bulk Refuse Container Application/Permit

2. Contact Information

4. Application Status

   1. New
   2. Renewal
   3. Temporary

5. 

7. Refuse Container Application/Permit

9. Company Name

10. Billing Name

12. Address

14. City

15. State

16. Zip Code

18. Telephone Number*

19. Fax Number

20. Email Address*

22. Container Address

24. Address

26. City

27. State

28. Zip

30. Type of Service*

    1. Temporary
    2. Annual

31. Type Establishment

    1. Food Related
    2. Residential
    3. Number of Units Served
    4. Industrial

    1. Construction Site
    2. Commercial
    3. Other

32. Number of Units
    -- Select One --12345More than 5More than 10More than 100

34. If Other

36. Agreement
    <ul> <li>I agree to conform to the ordinances governing the use of bulk containers and will permit such inspections and examinations as may be deemed necessary by the Director of Public Health. </li> Copies of codes are available upon request. <li>I agree to notify the Bureau of Environmental Health Services immediately of any changes in management, services or when the applicant ceases to be responsible for the bulk container. </li> <li>I understand that this permit is valid only for the location for which it was issued and is not transferrable from one location to another; nor from one owner to another. </li> </ul>

    • I agree to conform to the ordinances governing the use of bulk containers and will permit such inspections and examinations as may be deemed necessary by the Director of Public Health.
    Copies of codes are available upon request.
    • I agree to notify the Bureau of Environmental Health Services immediately of any changes in management, services or when the applicant ceases to be responsible for the bulk container.
    • I understand that this permit is valid only for the location for which it was issued and is not transferrable from one location to another; nor from one owner to another.

38. Note: It is recommended that the bulk container site plans to be reviewed prior to construction.

40. Applicant's Signature

41. Date
    Date

43. Print Name

44. Title

46. Payment Type
    -- Select One --CheckMastercardVisa

47. Credit Card Number

48. CCV

49. Expiration Date
    Expiration Date

51. Cardholder's Name

52. Signature

54. Please make checks payable to:

56. Norfolk Department of Public Health
    830 Southampton Ave
    Norfolk, VA 23510

58. Permit Number:

59. Issue Date:
    Issue Date:

60. Expiration Date:
    Expiration Date:

61. PD:

63. Rect Date
    Rect Date

64. Invoice Number

65. Check Number

66. Received By:

68. Ecode:

69. Site Inspection by:

70. Date:
    Date:

72. Exempt:
    -- Select One --YesNo

73. Approved By:

74. Date:
    Date:

76. CashBook Date:
    CashBook Date:

77. By:

78. Posted Date:
    Posted Date:

79. By:

Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit Submit and Print

* indicates a required field