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SCMU Application - Inside City Refuse

SANTA CRUZ MUNICIPAL UTILITIES (SCMU)

CITY COMMERCIAL ACCOUNTS

REFUSE (ONLY) SERVICE SIGN-UP

1. SERVICE LOCATION INFORMATION

Service Address - Street, Apt/Ste:*

Service Address - City, State, Zip Code:*
Requested Service Start Date (No weekends or holidays):*

Requested Garbage Cart Size:*
Requested Dumpster Size:*
Dumpster Pickup Frequency:
Dumpster placement on site? (Street placement is not allowed unless approved in advance by the Public Works Department)

What type of material will be in the dumpster?

The applicant agrees to comply with the Container Rental and Indemnification Agreement (Mandatory if requesting dumpster service): I hereby agree to indemnify, defend and hold the City of Santa Cruz, its agents and employees harmless from any claims for damage, death or personal injury which may result from the dumpster's use, movement or placement during the course of its rental through this account with the City of Santa Cruz. This agreement does not extend to liability arising from the negligence or intentional misconduct of city staff, as determined by court judgement.

2. APPLICANT INFORMATION

Business Name:*

Owner/ Corporate Officer Name:*

Billing Address - Street, Apt/Ste:*

Billing Address - City, State, Zip Code:*

Primary Phone Number:*

Alternate Phone Number:

E-mail Address:

Business Type:*
Tax ID/ Driver's License/ ID Number:*

Issued By (State or Country):*

City Business License Number:*

Previous Service Address with SCMU

I DECLARE UNDER PENALTY OF PURJURY THAT 1) I AM THE RESPONSIBLE PARTY AT THE SERVICE ADDRESS AND/OR AN AUTHORIZED REPRESENTATIVE OF THE BUSINESS, AND 2) THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.

3. OFFICE USE ONLY

Account # --- Meter # --- Location
Deposit Receipt # --- Field Remarks