Garbage/Industrial Waste & Domestic Appliances Removal Form
This form is used for the following:
to report any concerns about garbage in a particular location.
to request the removal of Industrial Waste & Domestic Appliances.
Your Information
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 000-0000.
Garbage/Waste Removal Location
Location of Garbage/Waste
*
Give as detail description as possible for the location.
Is the garbage yours or someone else?
*
Mine
Someone else
What type of Garbage/Waste?
*
Household Garbage
Industrial Waste
Domestic Appliances
Yard Trash - Tree, grass, etc.
Other
Give details of Other
Any further details...(quantity, time it has been there, etc.)
Submit pictures of Garbage/Waste (if available).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: