DUST PERMIT INFORMATION Fax 702 398-7412


PERMITTEE:_________________________________________________________________________

ADDRESS: ________________________________________________ZIP CODE__________________

PHONE: ____________________ FAX: ______________________ CELL: _______________________

PROPERTY OWNER: _________________________________________________________________

CONTACT NAME: _________________________ ADDRESS:_________________________________

______________________CITY:_________________________ STATE:________ZIP ______________

PHONE: ____________________________________________ FAX: ____________________________

PARCEL # ______________________________________________ ACREAGE: __________________ 

PROJECT NAME: _____________________________________________________________________

PROJECT ADDRESS: _________________________________________________________________

PROJECT DESCRIPTION: ____________________________________________________________

RESPONSIBLE PERSON FOR DUST CONTROL: ________________________________________

CO. NAME & ADDRESS: ______________________________________________________________

PHONE: _______________________ FAX: _____________________ CELL : ____________________

ON SITE SUPERINTENDENT/SUPERVISOR: ____________________________________________

CO. NAME & ADDRESS: _______________________________________________________________

ON SITE PHONE: ______________________________________ CELL: ________________________

CLASS CERTIFICATION #: ________________________ EXPIRATION: ______________________

WATER SOURCE (CIRCLE): Water Truck   Hydrant w/Jones Valve   Stand Tank   Fire Hose

Ponds  Well  Other ___________________ Will there be Off-Site Work? YES/NO If you answered

yes, did you include this in your acreage? Approved County/City Plan # for off-sites _____________

YOUR JOB # _________YOUR PO # ______________   Do you need us to fax you a 1099? yes/no

DEMOLITION INFORMATION: (COMPLETE ONLY IF YOU ARE DOING A DEMOLITION)

DESCRIBE DEMO TO TAKE PLACE: ___________________________________________________

SIZE OF BUILDING: ______________s.f. YEAR BUILDING WAS BUILT: ____________________

NUMBER OF FLOORS OF BUILDING: ______NUMBER OF BUILDINGS ON SITE: __________ 

NUMBER OF BUILDINGS TO BE DEMOLISHED: ________________________________________

WASTE TRANSPORTER NAME, ADDRESS, PHONE & FAX #: _____________________________