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)
Date: ____________
Today’s Date
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 _______________________________________________
Other
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,
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
