HomeMy WebLinkAbout1383 Exemption Request Village Medical Square 23525 Golden Springs Drive.pdfi t y 0 r
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SEP 114 b%4383 ORGANICS RECYCLING REGULATIONS
WAIVER REQUEST FORD!
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INi MULTI -FA yq;G MPLE N. 1 BUSINESS LIQ ENUMBER—
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INESS OR WIJI-FAMIY PHYAICAL ADDi DATE SUBMITTED
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BUSINESS OFFICE MAILING ADDRESS J _. r'CITY STATIE
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CONTACT INFORMATION (fordesignated business representative who should receive walverrelated notices from the 04).
C ntact Name/Title
Phone Number E-Mail
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7E] THIRD -PARTY WAIVER (if you have a landscape contractor and/or other organics recycler)
Please provide the following information to request a Third -Party Recycling Waiver.,
• Third -party organic waste recycling service information:
> Recycler(s): 1), Business Lic #: Self -Haul Permit #: Phone:
2) Business Lic #: Self -Haul Permit #: Phone:
.;o Material type(s): Est. recycled per week: _ gallons OR cubic yards
Fa cilit(ies) where this material is taken for recycling
WAIVER FOR BUSINESSES/PROPERTIES WITH MINIMAL ORGANIC WAS T E (De Minimis Waiver)
Please provide the following information to request a low -wake generator "de minimis" waiver
• Average number of employees orsite:
• Does your business have a cafeteria providing meals to employees?
• Estimated number of employees that eat mealsisnacks onsite.-
• Contracted landscaper service information: lit hd &tAl
Landscaper name: Business License #:
Self -Haul Permit #., Phone:
• Average amount of organic waste collected per week:
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2 cubic yards of waste and < 20 gallons of organics ery (rec �S Jr y el'mell
2 cubic yards of waste and < 10 gallons of organics.,_ I& L4 (/OL�m I
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SPACE CONSTRAINT WAIVER
Please provide the following information to request a Space Constraint Waiver.
• I have documentation that soace constraints preclude placement of green waste and/or food waste recycling
containers at my business. No (Please attach documentation)
• I have worked with the City to determine that we cannot adjust container sizes or make other such changes to
resolve the space constraint issue. No
• Please indicate the specific program(s) you are requesting a waiver for:
Green waste recycling only = Food waste recycling only = Green waste & food waste
By signing this form, you are attesting that you have a full understanding of your business'/property's obligations to provide information,
report to, and otherwise fully cooperate with the City, as detailed in the instructions her whit r-„any, is form.
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Printed Name, Title and Signature of Adthorized Business Representative 'bate
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