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2. Permit Issued To:
4. Company Name:*
6. City/Town:*
7. Province:*
8. Postal Code:*
10. Contact Name:*
11. Phone Number:*
12. Email:*
14. Product Name:*
15. Notes:
17. Safety Data Sheet (SDS) Submitted:*

    1. Yes
    2. No
18. Submit Safety Data Sheet (SDS) here:
20. Conditions of Permit:

    1. All work on public property is to meet or exceed Occupational Health and Safety (OH&S) Legislation and Regulations.

    2. All work on public property is to meet or exceed standards and guidelines set by County bylaws, and Provincial and Federal legislation.

    3. A Safety Data Sheet (SDS) of the proposed dust control product must be submitted to the County for approval. Approved dust control products include chlorides, polymer blends, lignosulfonates, water, and other plant-based products. Hydrocarbon and petroleum products are not permissible (i.e.: asphalt oil, crude oil, emulsions, used motor oil, etc.).

    4. The road segment to be treated shall be clearly demarcated by the Applicant so that the County Patrol Operator is aware of its existence. It is the responsibility of the Applicant to place and maintain demarcation flags at the beginning and end of the dust control segment.

    5. The roadway shall be smooth, contour-free of ruts and washboard prior to the application of dust control.

    6. The County will not expend special efforts to blade and shape or add aggregates to the road segment prior to it receiving the dust control application. The dust control road segment will not be pre-inspected or post-inspected by the County.

    7. The allowable seasonal application of dust control shall be limited to the time period inclusive of May 1st to September 1st.

    8. Seasonal road bans may be in effect at time of application and shall be strictly adhered to.

    I further acknowledge that the County reserves the right to maintain and upgrade the roadway, and should such activities remove or disturb the dust control, I, or the landowner shall not be entitled to a free application of dust control, or any other form of compensation from the County.

    I hereby remise, release, and forever discharge the County, its officers, contractors, agents, servants, successors and assigns of and from all manner of actions, causes of actions, suits, debts, dues, accounts, covenants, contracts, claims, and demands whatsoever which I shall or may have by reason of any cause, matter or thing, whatsoever, and without limiting the generality of the foregoing, from all claims for damages arising in any way whatsoever as described herein and as a result of the private, third-party dust control application.

22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, and 2) by signing in this alternate manner, your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I acknowledge that I have received, read, and understand all of the above, and I further acknowledge my commitment to the conditions stated in this Permit.
24. Electronic Signature*
25. Date:*
    Date:
27. Freedom of Information and Protection of Privacy Act

    Section 33(c) of the FOIP Act authorizes the County of Wetaskiwin No. 10 to collect this personal information for the purpose of "pre-approving contractor to apply dust control on County roads". If you wish to inquire about the collection, use, and disclosure of personal information, or if you have questions about correcting your personal information, please contact the FOIP Coordinator: foip@county10.ca; phone 780-352-3321 (ext. 2270); or, toll free at 1-800-661-4125.

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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field