Application For Curbside Registration Form Page 2
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4AGENCY INFORMATION
5)
Name of Responsible Public Agency (City/County/District) __________________________________________________________________________
What Community/Communities Served by this Program _____________________________________________________________________________
Contact Person _________________________
________________________________
_________________________________________
_______________________
First
Middle
Last
Title
County _________________________________________
Public Agency Department ________________________________________________
Business Address ___________________________________
_________________________
___________________________
___________
_______________
Address
City
County
State
Zip Code
Mailing Address ____________________________________
_________________________
___________________________
___________
________________
Address
City
County
State
Zip Code
(
)
Telephone Number ( _______________________________________________
)
_______
________________________________________________________________
Fax
6) Initial Program Start Date
_________________________________________________________________________________________________
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7) Is the operator of the curbside program currently certified by CalRecycle, Division of Recycling, in any category? .............................................
Yes
....
No
If YES, list all valid Certification Number(s) _______________________________________________________________________________________________
8) Provide a dated and signed copy of the current contract, franchise agreement or letter from the responsible public agency, administrative
officer or designee.
9) Expiration Date of current Acknowledgment or Agreement __________________________________________________________________________
10) Provide a current map showing boundaries of the curbside program.
PROGRAM INFORMATION
11) Number of Households Served
_________
Single family residences
_________
Multi-family (2-4 units) residences
__________
Apartment (units) residences
12) Do you also collect empty beverage containers directly from (Check all that apply)
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❏
❏
❏
Office buildings
Industrial buildings
Hotels, motels, bars, or restaurants
Other businesses
13) Frequency of Collection (Check all that apply)
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❏
❏
❏
Single Family
Weekly
Every 2 weeks
Twice Monthly
Monthly
❏
❏
❏
❏
Multi-Family
Weekly
Every 2 weeks
Twice Monthly
Monthly
❏
❏
❏
❏
Apartments
Weekly
Every 2 weeks
Twice Monthly
Monthly
Other (describe) ____________________________________________________________________________________________________
_
14) Method of Collection (Check all that apply)
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❏
Single Family
At Curb Manual
At Curb Semi-Automated
At Curb Automated
Backyard
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❏
❏
❏
Multi-Family
At Curb Manual
At Curb Semi-Automated
At Curb Automated
Backyard
❏
❏
❏
❏
Apartments
At Curb Manual
At Curb Semi-Automated
At Curb Automated
Backyard
Other (describe) _____________________________________________________________________________________________________
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