OCR Scan (approximately)

This OCR scan may contain automatically generated text as generated using Apache Tika and Tesseract. It may not be correct. No effort has been made to correct any of these scans (so far). These OCR scans are also used in the site's Search feature. Please review the Search Policy for details about the site features. The OCR scan is provided here for reference purposes. It provides searchable text when the underlying document might not. But the scan process may not always work perfectly.

RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
INSTRUCTIONS:  Submit completed application to the Russell County Board of Supervisors, P.O. Box 1208 Lebanon, Virginia

Please make sure to complete & sign form before mailing and also keep a copy for your records.  Note: A complete

application includes submission of payment of annual fee as established by the Russell County Board of Supervisors and a list
of commercial establishments, institutional, and industrial entities/sites for which services are provided for in the county.
The Collector/Hauler permit will expire January 15 following the year for which issued.  Renewal of permit will be required
before expiration of permit.  Payment of annual permit fee should be made payable to the Treasurer of Russell County, Va.
HAULER/CONTRACTOR INFORMATION ☐ NEW APPLICATION  ☐ RENEWAL
☐ WASTE HAULER OR ☐ COLLECTOR ☐ COMPANY OR  ☐ CORPORATION
COMPANY/CORPORATE NAME: ____________________________________________________
CORPORATION COMMISSION ID NO. (if applicable): ____________________________________
PHYSCIAL ADDRESS: _____________________________________________________________
     CITY: ____________________ STATE: ____________ ZIP: ___________ 

MAILING ADDRESS: ______________________________________________________________
     CITY: ____________________ STATE: ____________ ZIP: ___________ 

PHONE: ________________ FAX: ________________ EMAIL: ____________________________
CONTACT PERSON: ______________________________________________________________
AGENT FOR SERVICE OF LEGAL PROCESS: ____________________________________________
PHYSCIAL ADDRESS: _____________________________________________________________
     CITY: ____________________ STATE: ____________ ZIP: ___________ 

PERSON COMPLETING THIS APPLICATION: ___________________________________________
LICENSE FEE INFORMATION
WASTE HAULING VEHICLES TO BE USED: (include proof of insurance for each vehicle)
MAKE   MODEL   VIN





ANNUAL FEE DUE: $500 PER ________TRUCKS USED FOR A TOTAL ANNUAL FEE OF __________
RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
INSTRUCTIONS: Submit completed application to the Russell County Board of Supervisors, P.O. Box 1208 Lebanon, Virginia
24266. Please make sure to complete & sign form before mailing and also keep a copy for your records. Note: A complete
application includes submission of payment of annual fee as established by the Russell County Board of Supervisors and a list
of commercial establishments, institutional, and industrial entities/sites for which services are provided for in the county.
‘The Collector/Hauler permit will expire January 15 following the year for which issued. Renewal of permit will be required
before expiration of permit. Payment of annual permit fee should be made payable to the Treasurer of Russell County, Va
HAULER/CONTRACTOR INFORMATION —[] NEW APPLICATION C] RENEWAL
(Co WASTE HAULER OR C] COLLECTOR Ci company or Cl] CORPORATION
COMPANY/CORPORATE NAME:
CORPORATION COMMISSION ID NO. (if applicable):
PHYSCIAL ADDRESS:
city: STATE: ZIP:
MAILING ADDRESS:
city: STATE: ZIP:
PHONE: FAX: EMAIL:
CONTACT PERSON:
AGENT FOR SERVICE OF LEGAL PROCESS:
PHYSCIAL ADDRESS:
city: STATE: ZIP:
PERSON COMPLETING THIS APPLICATION:
LICENSE FEE INFORMATION
WASTE HAULING VEHICLES TO BE USED: (include proof of insurance for each vehicle)
MAKE MODEL VIN
ANNUAL FEE DUE: $500 PER TRUCKS USED FOR A TOTAL ANNUAL FEE OF
RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
APPLICANT CERTIFICATION & SIGNATURE
THE UNDERSIGNED APPLICANT SHALL COMPLY WITH ALL APPLICABLE REQUIREMENT OF THE RUSSELL COUNTY SOLID WASTE
MANAGE ORDIANCE AND FURTHER AGREES TO THE FOLLOWING:
A. TO ONLY US COLLECTOR/HAULING VEHICLES IDENTIFIED WITHIN RUSSELL COUNTY, VIRGINIA;
B. TO PROVIDE ALL REQUIRED CERTIFICATIONS OF COMPLIANCE, INSURANCE, BONDS, AND LICENSES UPON
ISSUANCE OF A COLLECTOR/HAULER PERMIT;
C. TO DISPOSE OF ALL SOLID WASTE COLLECTED IN RUSSELL COUNTY AT THE RUSSELL COUNTY TRANSFER STATION
UNLESS SUCH SOLID WASTE IN QUESTION IS NOT ACCEPTED AT SAID TRANSFER STATION, OR IS SPECIFICALLY
EXEMPTED FROM DISPOSAL AT THE COUNTY TRANSFER STATION PURSUANT TO VIRGINIA CODE SECTION 15.2-933.
D. PERMIT ISSUED IS NOT TRANSFERABLE TO ANY PERSON, BUSINESS OR CORPORATION, FROM THE PARTY TO WHOM IT
WAS ORGININALLY ISSUED.
E. EACH INDEPENDENT OR PRIVATE COLLECTOR/HAULER MUST ABIDE BY THE COUNTY REPORTING & DOCUMENTATION
REQUIREMENTS.  DOCUMENTATION SHALL PROVIDE AT TIME OF APPLICATION AND AT OTHER TIMES UPON REQUEST
AN ACCURATE LISTING OF ALL COMMERCIAL ESTABLISHMENTS, INSTITUTIONAL, AND INDUSTRIAL ENTITIES/SITES
FOR WHICH THEY PROVIDE WASTE PICK-UP FOR IN THE COUNTY.  INFORMATION DETAILING THE SIZE (CUBIC YARD
MEASUREMENT) OF WASTE CONTAINERS AND NUMBER OF PICK-UPS PER EACH RESPECTIVE ENTITY.
THE APPLICANT UNDERSTANDS THE RUSSELL COUNTY, VIRGINIA BOARD OF SUPERVISORS MAY APPROVE THIS APPLICATION
CONTINGENT UPON THE APPLICANT SUBMITTING PROOF OF BOND AND INSURANCE, PAYMENT OF THE LICENSING FEE,
AND/OR CORRECTION OF ANY OTHER DEFICIENCIES THAT MAY EXIST AND THAT THE COLLECTOR/HAULER PERMIT WILL NOT BE
ISSUED UNTIL REQUIREMENTS ARE MET.  ANY CHANGES TO THE APPLICATION INFORMATION ABOVE SHALL BE THE
APPLICANT’S RESPONSIBILITY TO SUBMIT TO THE COUNTY.  THE UNDERSIGNED FURTHER CERTIFIES, UNDER PENALTY OF
PERJURY, THAT ALL THE INFORMATION SUPPLIED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF THE
UNDERSIGNED APPLICANT’S AND BELIEF.
APPLICANT SIGNATURE: ___________________________________________________________ DATE: ___________________
RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
APPLICANT CERTIFICATION & SIGNATURE
‘THE UNDERSIGNED APPLICANT SHALL COMPLY WITH ALL APPLICABLE REQUIREMENT OF THE RUSSELL COUNTY SOLID WASTE
MANAGE ORDIANCE AND FURTHER AGREES TO THE FOLLOWING:
A
B
‘TO ONLY US COLLECTOR/HAULING VEHICLES IDENTIFIED WITHIN RUSSELL COUNTY, VIRGINIA;
TO PROVIDE ALL REQUIRED CERTIFICATIONS OF COMPLIANCE, INSURANCE, BONDS, AND LICENSES UPON
ISSUANCE OF A COLLECTOR/HAULER PERMIT;
‘TO DISPOSE OF ALL SOLID WASTE COLLECTED IN RUSSELL COUNTY AT THE RUSSELL COUNTY TRANSFER STATION
UNLESS SUCH SOLID WASTE IN QUESTION IS NOT ACCEPTED AT SAID TRANSFER STATION, OR IS SPECIFICALLY
EXEMPTED FROM DISPOSAL AT THE COUNTY TRANSFER STATION PURSUANT TO VIRGINIA CODE SECTION 15.2-933.
PERMIT ISSUED IS NOT TRANSFERABLE TO ANY PERSON, BUSINESS OR CORPORATION, FROM THE PARTY TO WHOM IT
WAS ORGININALLY ISSUED.
EACH INDEPENDENT OR PRIVATE COLLECTOR/HAULER MUST ABIDE BY THE COUNTY REPORTING & DOCUMENTATION
REQUIREMENTS. DOCUMENTATION SHALL PROVIDE AT TIME OF APPLICATION AND AT OTHER TIMES UPON REQUEST
‘AN ACCURATE LISTING OF ALL COMMERCIAL ESTABLISHMENTS, INSTITUTIONAL, AND INDUSTRIAL ENTITIES/SITES
FOR WHICH THEY PROVIDE WASTE PICK-UP FOR IN THE COUNTY. INFORMATION DETAILING THE SIZE (CUBIC YARD
MEASUREMENT) OF WASTE CONTAINERS AND NUMBER OF PICK-UPS PER EACH RESPECTIVE ENTITY.
‘THE APPLICANT UNDERSTANDS THE RUSSELL COUNTY, VIRGINIA BOARD OF SUPERVISORS MAY APPROVE THIS APPLICATION
CONTINGENT UPON THE APPLICANT SUBMITTING PROOF OF BOND AND INSURANCE, PAYMENT OF THE LICENSING FEE,
AND/OR CORRECTION OF ANY OTHER DEFICIENCIES THAT MAY EXIST AND THAT THE COLLECTOR/HAULER PERMIT WILL NOT BE
ISSUED UNTIL REQUIREMENTS ARE MET. ANY CHANGES TO THE APPLICATION INFORMATION ABOVE SHALL BE THE
APPLICANT’S RESPONSIBILITY TO SUBMIT TO THE COUNTY. THE UNDERSIGNED FURTHER CERTIFIES, UNDER PENALTY OF
PERJURY, THAT ALL THE INFORMATION SUPPLIED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF THE
UNDERSIGNED APPLICANT’S AND BELIEF.
APPLICANT SIGNATURE: _ DATE:
RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
COMMERCIAL ESTABLISHMENTS, INSTITUTIONAL, AND INDUSTRIAL ENTITIES/SITES
FOR WHICH PROVIDE WASTE PICK-UP FOR IN THE COUNTY
NAME                             ADDRESS                         CONTAINER SIZE PICKUP PER WEEK/MONTH



















RUSSELL COUNTY, VIRGINIA
SOLID WASTE COLLECTOR/HAULER PERMIT APPLICATION
COMMERCIAL ESTABLISHMENTS, INSTITUTIONAL, AND INDUSTRIAL ENTITIES/SITES
FOR WHICH PROVIDE WASTE PICK-UP FOR IN THE COUNTY
NAME ADDRESS CONTAINER SIZE PICKUP PER WEEK/MONTH