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2. 
3. Utility Billing Department
   20 or 30 Yard Rolloff Application
5. Name of Business*
6. Setting Date*
   Setting Date
8. Applicant Name*
9. Driver's License #*
11. ID Required*
    Upload a copy of your ID.
12. Date of Birth*
    Date of Birth
13. Social Security #*
15. Phone #*
16. Email *
17. Fax #
19. Service Address for Container Setting*
    Lake Brownwood is outside city limits
21. Mailing Address: *
23. City
24. State
25. Zip
27. Billing Preference*
    -- Select One --Paper BillE-Bill
31. Onsite Contact
32. Onsite Contact Phone #:
34. How many loads do you expect to have? Enter Numbers above 0 only.*
36. How long will you need the container?*
    -- Select One --One dayOne weekOne month More than one month
38. Setting is for (example: cleaning out storage building)?*
40. What will be put in it?*
42. Size requested (preference will be taken into consideration)*
    -- Select One --20 CY30 CY

    Price is the same for all sizes / if hauling concrete a 20yd will be set.
43. Quantity requested:*
    -- Select One --123
45. Do you have a preference where you would like the container set?*
    The sanitation supervisor will take this into consideration
47. If deposit is required, will you be coming to City Hall make the payment? *
    -- Select One --YesNo
48. If no, would you prefer the paperwork:
    -- Select One --FaxedEmailed
50. Solid Waste Services
    NOTE: The container will NOT automatically be picked up at the end of the time specified. Please call 325-643-4200 for all empty and returns and final pickups.
52. I AGREE TO THE FOLLOWING:*

    Please check all boxes below to comply.

    1. I understand that I must pay a deposit based on the quote from the Sanitation Supervisor. Payment is made by contacting Utility Billing at (325)646-9700.
    2. I understand that government issued PHOTO IDENTIFICATION is required for service. A scanned copy or picture is fine.
    3. I understand that with my submission I am responsible for payment of the account.
54. Applicant Signature*
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field