TE 1_rev1.pdf

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DPW POC: PMCPOC:

Phone:

Email:

Phone:

Email:

Installation of Delivery: I POC Name:

Phone:

Alt Phone:

GPC Number: I

REQUEST FOR REFUSE CONTAINER FORM

COMPLETE ALL HIGHLIGHTED AREAS

I Building # I I Cardholder Name:

Phone:

Fax:

VN# I Expiration Date:)

(mark all yellow areas with quantity of each service as needed)

Requested Dates: Delivery Date._! _____ _. Removal Datl._ _____ _.! Rental Days per Bin :

: lultiplied by Total Sey Bins

Multiplied by Total JOcy B Multiplied by Total 40cy B

Total Rental Days.

CONTAINER TYPE

QUANTITY AND SIZE: Dea Sey (small only for trash) Dea 10cy (concrete only) Dea 40cy {large any listed below

IF SERVICE TO BIN IS NEEDED (REMOVE FULL BIN & DELIVER EMPTY BIN)

NUMBER OF SERVICE Dea Sey (small trash only)

List Service Dates:

Dea 10cy (concrete only) Dea 40cy (large any listed below

TYPE OF WASTE (place an "X" to indicate what you're disposing. Each different "X" needs a different bin)

□Bulk Furnitun Oconstuction Debris □concrete Doreen Waste □Metal □Trash & Loose Wood

(For Official Use Only - Please DO NOT fill) Task Order # I I GPC I I

CLIN DESCRIPTION UOI UNIT UP TOTAL

Sey Delivery & Removal 0 EA $ $

8cy Service 0 EA $ $ Sey Rental Days 0 EA $ $ IOcy Delivery & Removal 0 EA $ $ 1 0cy Service 0 EA ,$ $

1 0cy Rental Days 0 EA $ $ 40cy Delivery & Removal 0 EA $ $ 40cy Service 0 EA $ $ 40cy Rental Days 0 EA $ $

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