DUMPSTER / APPLIANCE REQUEST

DATE OF REQUEST

NAME OF CUSTOMER

ADDRESS OF CUSTOMER

PHONE NUMBER

DIRECTION ON PLACÉMENT / ITEM TO PICKUP

Note: If dumpster place in driveway OR over a sidewalk they need to sign liability release.

Dumpster Request (check one)

1.5 YD: $25.04 / dump3.0 YD: $50.07 / dump6 YD: $100.15 / dump

APPLIANCE/JUNK ITEM

Check one:

$17.00 Regular appliance/junk item$29.00 freon-appliance

DATE TO DROP OFF

DATE TO PICK UP

Check One:

Pre-PayUtility BillHandbill

Acct No

Util Due Date

Date

When the City of West Liberty delivers dumpsters to your residence or any other property of your choice, they are delivered by our city garbage trucks. The garbage trucks weigh many tons and will put pressure on your driveways and your property. The City of West Liberty is not responsible for any damages incurred to your property by delivering the dumpsters. If you desire that a dumpster be placed in your driveway or on your property, you as the property owner will be liable for any damaged incurred.

By signing this form you release the City of West Liberty from any responsibility for damages incurred on your property.

*Dumpsters will be delivered on Friday and picked up on Tuesday or delivered on Tuesday and picked up on Friday only.

**Bricks, concrete, tree stumps, construction material, shingles, batteries, medical waste, appliances, tv's, paint, paint cans, oil jugs, oil, fuel filters, e- waste, tires, steel (or other metal), and hazardous materials are not allowed in the dumpsters. Furniture that does not fit in dumpster will not be allowed. All material that is placed in dumpster has to fit inside and must not be overflowing.

Customer Signature

Address of Dumpster Delivery

Date

Are you the owner of this property?

YesNo

If. you are not the owner, the landlord must sign liability release. The City of West Liberty does not loan dumpsters out to tenants without landlord signature on liability release.

DUMPSTER / APPLIANCE REQUEST

DUMPSTER RENTALS