Tire Disposal Request Form

TIRE DISPOSAL REQUEST FORM
Must be a Village/Town Resident
Name *
Street Address: *
Mailing address (if different than street) *
Phone Number *
Public Works will call the number provided to schedule pick-up.
Email
example@example.com
Address/location for tire pick up *
(Address must be in the Village/Town of Somers)
SPECIAL DIRECTIONS:
******RIMS MUST BE REMOVED******
TIRE TYPE
Number of Tires
Unit Price Automobile
MULTIPLY UNIT PRICE $5.00
Number of Tires
Unit Price Light Truck
MULTIPLY UNIT PRICE $5.00
TOTAL
Office Use Only
Recpt. Code PWC
Method of Payment
Cash:
Check #
Public Works
Phone Number
Date Called

Month Day Year
Date
Pick Up Date

Month Day Year
Date
Should be Empty:

TIRE DISPOSAL REQUEST FORM