Town of Greenwich Dept. of Public Works
Waste Disposal Division
Owner Verification Form
Name of Greenwich Resident or Property Owner
Street Address of Greenwich Resident or Property Owner
City State Zip Code
Telephone Number of Resident during Holly Hill Facility Hours (M-F 7-2:30; Sat 7-12)
To: Weigh Master, Dept of Public Works:
I have retained ________________________________________ to deliver the following
materials to the Town of Greenwich, Holly Hill Facility on my behalf. He/She will deliver the
following materials from my above listed Greenwich property ONLY. Circle one or write-in, below.
Yard Waste/Logs/Leaves Construction Debris _______________________________________________
I estimate the volume of material being delivered to the Holly Hill Facility from my above listed
Greenwich property to be the following: Circle one or write-in, below.
_____ number of cubic yards or <fills the bed of one pick-up truck or fills the bed of one pick-up truck
or > fills the bed of one pick-up truck or ___________________________________________________
Best describes the volume of material being delivered
I understand that I am responsible for the material my agent delivers to the Holly Hill Facility.
I understand my material must be source separated (that means construction debris with construction debris,
yard waste with yard waste, trash separated from construction debris, recyclables separated from trash, etc,
I understand there may be a charge for my material which must be paid at the time of delivery.
My agent understands that he/she must cross the scale and provide this original letter, signed by me (the
Greenwich property owner) and addressed to you (the Weigh Master) for each load delivered.
Signature of Greenwich Resident or Property Owner Date