2. 

3. 
   

   
   ROLL OFF APPLICATION FORM FOR TEMPORARY DUMPSTER SERVICE

   
   

4. City of Tarpon Springs

   Utility Billing Division

   PO Box 5004

   Tarpon Springs, FL 34688-5004

   Phone: (727) 942-5609  Email: ubcts@ctsfl.us

8. Arrangements should be made at least 48 hours prior to delivery of container. Due to the size and weight of the equipment, it is the responsibility of the owner of the property to provide a safe, accessible area, which is clearly marked for proper placement. A 30-yard container cannot be ordered if you are disposing of extremely heavy materials such as cement, rock, or roofing materials.

   Once the container has been placed at the designated property, it becomes the customers' responsibility to maintain service within a reasonable timeframe. A container with no activity over a two-month period will be subject to a rental fee.

   Section 8-13 of the City code provides that only the City may collect and dispose of waste. Because the City contracts with Waste Management for collection and disposal, roll off containers that are available from Waste Management must be used. 

   *After calling WM for final pick up, you must submit a written request to Utility Billing in order for your deposit to apply*

   ***** The phone number to call for service is: (727) 572-8779 *****

   *Rates are subject to change October 1^st and are applicable to all containers*

10. Roll off Charges are as follows:

12. Choose one:

    1. 30 yard*
    2. 20 yard
    3. 10 yard

13. 
    $711.08 per pull plus
    $711.08 per pull plus
    $711.08 per pull                plus

14. 
    $61.20 per ton - tipping fee               $1300.00 deposit
    $61.20 per ton - tipping fee               $1300.00 deposit
    $61.20 per ton - tipping fee               $1300.00 deposit
    

16. *

    If you order a 30 yard and there is not one available, do you want a 20 yard instead or do you want to wait for a 30 yard to be available?

18. All above costs include an administration fee of 20%. Charges will be billed to your utility account following service.

    
    Roll off charges are usually  billed within two months of the pull date, the charges will vary according to weight of the container for each pull***

20. I have read and understand charges and agree to conditions as stated above.

22. First Name*
23. Last Name*
25. Electronic Signature*
26. Date*
    Date
28. 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.
30. Service Address*
32. City
33. State
34. Zip Code
36. Mailing Address

    (If different than service address)

38. City
39. State
40. Zip Code
42. Cell Phone*
43. Home/Work Phone
45. City Account #*
46. Waste Management Account #
48. Requested Delivery Date*
    Requested Delivery Date

    (To be approved by WM)

49. Where should we place container?*
51. 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.
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field