Customer Information Form

Name of Business:
Owner(s)/Manager(s):
Business Address:
City:
State:
Zip:
Phone:
E-mail Address:
Contact Person(s):

Total number of Business Trucks that will utilize Landfill:   

Truck Model:		Description:
Truck Model:		Description:
Truck Model:		Description:
Truck Model:		Description:
Truck Model:		Description:
Truck Model:		Description:
Truck Model:		Description:

Person(s) authorized to sign weigh tickets:

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Credit References:

(Applies to non-county residents only)

Name	Phone Number
Comments: