City of Piedmont
Donation Bins & Vending Machines
Registered Owner of Bin or Vending Machine:
Date: __________________________ Full Name: __________________________________________________
Company Name: _____________________________________________________________________________
Street: _______________________________________
City: _________________________________________
State: _____________ Zip Code: _______________
Mailing Address (If Different)
Street: _______________________________________
City: _________________________________________
State: _____________ Zip Code: _______________
Phone Number: _________________________ Cell Phone Number: _____________________________
Fax Number: __________________________ E-Mail Address: ____________________________________
Placement Address of Donation Bin and/or Vending Machines: ________________________________
____________________________________________________________________________________
Type of Donation Bin and/or Vending Machine: _____________________________________________
******************************************************************************************
Office Use Only
□ Permit #: _________________________________
□ Written Consent from Property Owner
□ Plot Plan (depicting setback to the property line &
distances from other structures on the lot)
□ Certificate of Liability Insurance (1 million dollars
for each donation bin placed)
$________________________________________
Receipt Number: ___________________________
Date Posted: ______________________________
Approved by: ________________________________________ Date: ________________________________________
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