EPA Service Request Form 2023

Please Select a Topic:*

Senior AssistanceIllegal Dump ReportCommunity Clean-up Day AssistanceBulky Waste Pickup Request

Bulky Waste Pickup Request

Please describe your message or need in detail:

Are you the homeowner?*

YesNo

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Service Address*

Please attach a copy of your CDIB or Tribal membership.

Attestation:

By accepting this assistance, I hereby grant the Cheyenne and Arapaho Tribes Environmental Protection Agency (EPA) program, and its employees, its assigns, agents, and subcontractors hereby referred to as "Service Providers" permission to enter upon my property for the collection of said items as described on attached "Request for Services

I hereby waive and release the Service Providers from any claims that may arise from said collection. I will not hold the Cheyenne and Arapaho Tribes, the Tribal EPA, and its Service providers liable for any damages that may occur including driveways, house, fence, yards, or vehicles while conducting said collection.

Property Owner Signature*

Clear

Date*

Date

PLEASE SEND FORM AND CDIB TO: rfrench@cheyenneandarapaho-nsn.org or

EPA, PO BOX 167, CONCHO, OK 73022