Cancel/Temporarily Stop or Reinstate Refuse Collection Service

Name Account # (if known)

Street Address

Billing Address

City, State, Zip Code

Daytime Phone

Home Phone

Cancel Service - Please respond to the following:

Are you a Renter? Yes No

Requested cancel date?

Forwarding Address:

Forwarding Phone #:

Temporarily Stop Service

Requested Stop Date? Requested Start Date?

Reinstate Service

In Yard Collection? Pick one... 300' driveway - $11.50/month longer than 300' driveway - $15.00/month