Please provide the following contact information:

                                           Permit No.

CREDIT REFERENCES

   1) Name:

        Phone:

    Address:

   2) Name:

        Phone:

    Address:

    3) Name:

        Phone:

    Address:

Select any of the following options that apply:

Billing contact Person   
Type Of Trucks Expected To Access Landfill
Expected Frequency Of Landfill Trips Per Day    

_____________________________________________________

Choose one of the following options:

 

Type of Refuse Collected Industrial Commercial Residential

______________________________________________________

I am personally responsible for all bills and I submit the information on this application and authorize The Coastal Partnership to investigate my credit responsibility through banks, credit reporting agencies and other financial sources.

Name:     

Signature:

SS #       

Date: -- mm/dd/yyyy

______________________________________________________
TRUCK INFORMATION

 TRUCK TYPE	LICENSE NUMBER	   TARE WEIGHT