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2. REQUEST FOR DISCONNECT

   DISCONNECT REQUESTS AND CHANGES TO DISCONNECT REQUESTS MUST BE SUBMITTED 24 HOURS IN ADVANCE OF DESIRED DISCONNECT DATE.  

   Please keep in mind we cannot back-date any requests.  Disconnects will be completed on regular business days between 8am and 4pm.  

3. TYPE:*

   1. New Request

   1. Update to existing request
5. ACCOUNT HOLDER NAME:*
6. ACCOUNT NUMBER:
8. SERVICE ADDRESS: *
9. REQUESTED DATE OF DISCONNECT:*
   REQUESTED DATE OF DISCONNECT:

   Requests received after 3pm will be addressed on the next business day.  
   Requests to back-date a disconnect will not be honored but will be addressed the next business day.  

11. Number of polycarts on site: *
    -- Select One --12345

    Regular trash (black lid)

12. Number of Recycle carts on site:*
    -- Select One --12345

    (yellow lid)

14. IS A NEW OCCUPANT MOVING IN?:*

    1. UNKNOWN
    2. YES
    3. NO
15. Your Phone Number*
17. FORWARDING ADDRESS for any refund / final bill:
19. Address*
21. City*
22. State*
23. Zip Code*
25. SIGNATURE: *

    Disconnect requests and changes to disconnect requests must be submitted at least 24 hours in advance of the desired disconnect date.  Requests to reconnect after a disconnect has been completed may result in a reconnect fee of $50.  Disconnects will only be completed between the hours of 8am and 4pm on regular business days.  Requests dated for a weekend or holiday will be completed the next business day.  In the case of a dispute, this record on file will serve as official notice of request to disconnect and the account holder will be responsible for applicable charges.  By completing the above signature block you agree to these terms.  

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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

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