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2. Account & Billing Information
4. Utility Billing Account Number:
   *Please provide, if using for residence*
5. Name to Bill to:*
7. Address to Bill to:*
8. Contact Phone Number:*
10. City*
11. State*
12. Zip Code*
14. Email Address:
    *Please provide an email address so we may email you a receipt
18. Service Address:*
    *Where will the dumpster be delivered*
20. Date to Deliver Container:*
    Date to Deliver Container:
21. Date to Remove Container:
    Date to Remove Container:
    *Must call 360.293.1921 for hauls and removal*
23. Delivery Fee Required:*

    1. 10 Yard - $436.13 (Delivery, 7 days, & 1 x haul)
    2. 30 Yard - $436.13 (Delivery, 7 days, & 1 x haul)

    ~The day of deliver starts the first day~ *Once you have submitted the form we will contact you by phone to receipt in payment*

25. Extra Fees:

    1. All tonnage fees - $103.00 per ton
    2. Container fees - $23.39 per day - starting on the 8th day
    3. Extra haul fees - $257.27 per haul - after first haul

    *I understand tonnage will be billed separately along with daily fees in excess of the original seven (7) days, and any extra hauls, along with state refuse taxes*

27. What is included in your deposit:
    Deliver, 7 day rental, 1 time haul, state refuse taxes
28. What is NOT included in your deposit:
    Tonnage, extra hauls, daily fees over the 7 days, additional state refuse taxes
30. **Must Read and Accept these Terms & Conditions:
    Container Rules: • Must be accessible for the collection vehicle and placed on approved level surface • Loaded evenly, not overloaded, and fill to rim or designated fill line • Must dump by gravity alone (crew will not remove waste by hand) • 6 & 8 yard containers are available for solid asphalt roofing material • Loose material must be bagged and tied to eliminate flying debris from container • Container and vehicles may cause damage to surfaces due to weight • The customer is responsible for any and all damage to the container incurred while it is in the Customer’s possession. • The customer agrees to defend, indemnify and hold City of Anacortes harmless from any and all claims, demands, losses, and liabilities to or by third parties relating to bodily injury or property damange involving the container at the job site. Prohibited Materials: • Animal waste or carcasses, medical waste • Blocks of concrete, rocks, heavy metal objects, large car parts, metal pipe • Hazardous and toxic waste, paint, oil, grease, antifreeze, solvents, material with asbestos content • Materials containing excessive amounts of water • Rechargeable or large batteries • Recyclable or compostable materials including sod, brush, etc.
32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Electronic Signature*
35. Date Signed*
    Date Signed
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field