COMPANY INFORMATION
(This information is required to obtain your FOG Permit Number)
Company Name: Todays Date:
Contact Person: Job Title:
Street Address: P.O. Box:
Mailing Address: Email Address:
City: State: Zip Code:
Phone Number: Fax Number: Contact Number:
Company Website:
Please enter the type of Commercial Waste Permit your company has:
(Example: NPDES, LAS, Industrial Pretreatment by Division or Industrial Pretreatment by Pretreatment Authority)
Type of Commercial Waste Permit: Permit Number:
Type of Commercial Waste Permit: Permit Number:
Type of Commercial Waste Permit: Permit Number:
Has your company Registered with the State of Georgia before? If Yes Previous FOG Number:
Does your company Transport Commercial waste pumped in Georgia across State lines?

GENERAL COMPANY INFORMATION:
(This information is not required but is information about your company that will be on the Georgia's List of Approved Commercial Waste Haulers)
Company Name: Street Address:
City: State: Zip Code:
Phone Number: Fax Number:
Total Number of Trucks: Years in Business:
How Do You Service Customers?
(Examples: Contract, Regularly Scheduled Times, Call When Needed)
and/or

Please Select The Types of Service You Provide to Customers:
(please select all that apply to your business)

Grease Traps Septic Tank Oil / Water Separators Grit Traps Sand Traps
Other
Please Select The Service Areas For Your Business:
(Use the Map and Select Your Range of Service select all that apply)

Region 1 Region 2 Region 3 Region 4 Region 5
Region 6 Region 7 All of Georgia

I certify that this document was prepared under my direction or supervision in accordance with
the system designed to assure that qualified personnel properly gathered and evaluated the
information submitted. The information provided is to the best of my knowledge and
belief, true, accurate, and complete.

Signature:
Please print your name in the space above