Fillable Drop Off Bin Application TC-21 rev. 1/17 ONLY (Town of Brookhaven)

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Drop Off Bin Application TC-21 rev. 1/17 ONLY (Town of Brookhaven)

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Drop Off Bin Application TC-21 rev. 1/17
One Independence Hill, Farmingville, NY 11738 Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk (631) 451-9101 FAX: 451-9264
Page 1 of 2
ONLY CHARITABLE ORGANIZATIONS RECOGNIZED PURSUANT TO IRS CODE §501(C)(3)
ARE PERMITTED TO APPLY FOR AND OBTAIN A DROP-OFF BIN PERMIT.
Brookhaven Town Code §43-4 requires applicants to supply a copy of the organization’s 501(C)(3) exemption and a
copy of the property's site plan indicating the drop-off bin location. If no site plan is available, a survey will be accepted.
APPLICANT INFORMATION:
Name of Organization:
Address:
Contact Person: Phone #:
IRS Employer Identification #: Alt Phone #:
COPY OF THE ORGANIZATION’S 501(C)(3) EXEMPTION MUST BE ATTACHED
PLACEMENT OF PROPOSED BIN LOCATION:
Tax Map Number: Map: 0200 Section: Block : Lot :
Bin Drop Off Address:
Description of Bin Location:
SITE PLAN OR SURVEY WITH PLACEMENT OF BIN MUST BE ATTACHED
ORGANIZATION PLACING THE BIN:
Name: Phone #:
Address: Hamlet:
Contact Person: Alt Phone #:
BIN CONTENT INFORMATION:
Emptying Schedule:
Final Destination of Bin Contents:
$50 NON-REFUNDABLE FEE: (Make Check or Money Order payable to Donna Lent, Brookhaven Town Clerk)
Check#: Mone
y
Order: Cash:
I attest to this docum
ent with full understanding that I am swearing under oath to this fact and that swearing falsely or giving a
misleading or untrue statement subjects me to prosecution under New York State Penal Law Section 210.5.
____
_____________________________
STATE OF NEW YORK
(Applicant’s Signature)
COUNTY OF SUFFOLK
Sworn to before me this ____ day of __________________ , in the year of 20 ____ , before me, the undersigned, a Notary Public in and for
State, personally appeared _______________________________, personally known to me or proved to me on the basis of satisfactory
evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she execute the same in
his/her capacity and that be his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted,
executed the instrument.
____
_____________________________
(Notary Public)
For Office Use Only Permit #: Date Issued: Receipt #:
Drop Off Bin Application TC-21 rev. 1/17
One Independence Hill, Farmingville, NY 11738 Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk (631) 451-9101 FAX: 451-9264
Page 2 of 2
Form must be completed in full to be processed.
DATE: _________________
OWNER INFORMATION: THIS SECTION MUST BE COMPLETED FOR ALL APPLICATIONS.
(Separate sheets may be used for multiple owners.) Be advised that I am the owner of record of the
property referenced herein and hereby consent to this application. This acknowledges that this is not an
application for final approval pursuant to Section 276 of the Town Law and waives all time limitation
except as provided in the Subdivision Regulations in the Town of Brookhaven. By this application, the
owner does hereby authorize employees or agents of the Town of Brookhaven, in conjunction with this
application, to enter and inspect the project site as necessary.
Owner’s Name: ______________________________________________________________________
Address: ___________________________________________________________________________
Hamlet: _______________________________________ State: ________ Zip: __________________
Telephone #: _________________________________
*If owner is a corporation, give the name and title of responsible officer:
Name: ____________________________________________ Title: ____________________________
Telephone #: _______________ Fax: _______________ Email Address: ______________________
In Witness Whereof I have hereto set my hand this ______ day of ____________________ 20_____
I attest to this document with full understanding that I am swearing under oath to this fact and that
swearing falsely or giving a misleading or untrue statement subjects me to prosecution under New York
State Penal Law Section 210.5.
_______________________________________
(Owner Signature)
STATE OF NEW YORK ss:
COUNTY OF SUFFOLK
Sworn to before me this ______ day of __________________ , in the year of 20______ , before me, the
undersigned, personally appeared _________________________________ , personally known to me or
proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed
to the within instrument and acknowledged to me that he/she/their capacity(ies), and that by his/she/their
signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted,
executed the instrument.
____________________________________
(Notary Public)
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Drop Off Bin Application TC-21 rev. 117 ONLY (Town of Brookhaven)

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Completed 12 February 2021

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