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" ` � CI:�'Y OF DIAMOND BAR
� -��— DEPARTiVfENT OF COMMUNITY &DEVELOPMENT SERVICES
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_ 21810 Copley Drive,Diamond Bar,CA 91765
(909)839-7020 Fax(909)861-3117 Building Inspection Aotline(909)839-7027 PRESS
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Attachment A
Form for Non-Franchise Haulers for Construction and Demolition Requirements
Company and Project Info:
Name of licensed demolition contractor hauler or self hauling coinpany S�``�
Address of Company City
Zip Code Phone Number
Address and Name of Project Site
22`� ►�I l�ce.�L 12 �vt^2- 1�c1if� � �i�� �— , �(�-6 r
Type of recycleable material or waste materia] to be transported for this project '
l/'u� �'�Q-bri` ��a I��i�� �-�a-lS ,
Report Information: •
Please submit this information prior to final building inspection.
A report reflecting the following information:
, • The estimated volume or weight of construction and demolition debris,listed for each
material;
• The estimated volume or weight of construction and demolition debris that can be
diverted listed for each material;
� The estimated volume or weight of construction and demolition debris that will be
landf Iled as waste; and
s Identification of the vendor or facility that will collect or receive the construction or
demolition debris.
AB 939 Fee Payment:
Pay AB939 fee of$6.00 per bin and$40 per roll off for all non-franchise hauler containers
Type of Container number of container
Paid date(office use only) (revenue code CD Waste)
Agreement and Signature:
The property owner agrees to submit documentation to demonstrate compliance with the 50%diversion
requirement for construction debris and shall indemnify and hold harmless the City for damage and
liability,including any financial liability, fines and penalties, associated with using a non-City �
franchised hauler and failing to satisfy diversion requirements.
� I�IJ I�ID f3 . _ . .
Pro�erty Owner Signature Print Name Date ,
-�-� � 2,'� 1 •l0 -� �
Se f Hauler ignature Print Name Date
Last updated March 14,2008
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CASH , '�� REFUSE DISPOSAL RECEIPT MANUA�# �����'�
CUSTOMER INFORMATION
ACCT#: � nj t/�p �p DATE: I ' � � -� �
ACCT NAME: ��('S� LU/ S �2I�"�i I 2�Z
UCENSE: � � �2 ��(� W/MASTER I.D.# T(�U �J � �
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CITY: �I�ru-lv�-/r7 /��i � a�
; WEIGH IN , WEIGH BACK REFUSE TYPE
GROSS: ' � • � / GROSS: REFUSE ��1 ,J
. TARE: �' � � TARE: z HARD/HANDLE 3
NET: `�• � � NET: _ , MIN/REFUSE 4
� RATE: 3 �� �� � RATE: - ' GREENWASTE 6
- ,
FEES: FEES: � MIN/GREEN � 7
TOTAL: $ / ��. / v TOTAL: $ � OTHER �
REFUND/ADDT'L DUE: $
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