Fillable Solid Waste Special Collection Services Application (City of Hartsville)

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Solid Waste Special Collection Services Application (City of Hartsville)

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APPLICATION FOR SPECIAL COLLECTION SERVICES
***To be filled out by your doctor***
Name: ________________________________ Date: ___ /___ / ___
Phone: _________________________
Street address: _________________________________________________
Please state reason for request
__________________________________________________________
__________________________________________________________
Please specify request (Ex. Collect roll cart from side or rear of house)
__________________________________________________________
__________________________________________________________
Homeowner’s signature: __________________________ Date: ___ /___ / ___
Medical Doctor’s name: __________________________________________________________
Business address: _______________________________________________________________
Phone: ___________________________________
Doctor’s signature:
______________________________ Date: ___ /___ / ___
RETURN TO
City of Hartsville
Environmental Services
500 Poole Street
PO Box 2497
Hartsville, SC 29551
Fax 339-2880
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Solid Waste Special Collection Services Application (City of Hartsville)

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Completed 14 July 2020

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