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Date

REQUEST FOR RECYCLING CONTAINER(S) MUST BE LEGAL PROPERTY OWNER OR HAVE AFFIDAVIT ON FILE FROM PROPERTY OWNER Property Owner/Billing Name Service Address City

State

Zip

Phone

Mailing Address (If different from above)

Check Container Desired

[ ] Aluminum/Metal Container [ ] Newspaper Container

Legal owner will be responsible for recycling container(s). If lost or stolen, responsible party will be billed for them on the next Sanitation billing @$35.00 per container.

Legal Owners Signature

Print Name

Internal Use Account #

Subdivision

Aluminum/Metal Container #

Ordered

Delivered

Newspaper Container #

Ordered

Delivered

Copy to Virgin Valley Disposal

Sanitation 10 E. Mesquite Blvd., Mesquite, NV 89027 702-346-5295, www.mesquitenv.gov

By

Last Revised 2/28/2011