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HANOVER COUNTY

PUBLIC WORKS DEPARTMENT

SOLID WASTE DISPOSAL SERVICES

P.O. BOX 470

HANOVER, VA 23069

(804) 365-6181

APPLICATION AND AGREEMENT FOR SOLID WASTE DISPOSAL CHARGE ACCOUNT

COMPLETE EVERY ITEM – PRINT OR TYPE

1. Name of individual or official name of firm:___________________________________________________________

2. If Business,

Nature of entity:

Type of Business________________________________________

Corporation

Limited Liability Company

Tax ID#_______________________________________________

General Partnership

Limited Partnership

3. If Individual, Drivers License Identification

Sole Proprietorship/Individual

State of Incorporation or

Number___________________________________________________

Organization of Entity: __________

_____________________________

4. Addresses: Mailing: ________________________________________

Street/Physical: ________________________________________

5. Telephone #___________________ Fax #_______________________

Accounts Payable Contact________________________E-mail Address_____________________________________

6. If Business, Name of owner or authorized official responsible for payment:

Name________________________________ Title_____________________________________________________

7. Bank Reference, with phone number of contact person:

Bank __________________________________________________________________________________________

Name

Contact Person

Account Number

__________________________________________________________________________________________

Address

State

Zip

Phone #

8. The undersigned agrees for itself, its officials, agents and employees that all use of Hanover County solid waste

disposal facilities shall comply with all applicable ordinances, regulations and directives of County staff, including

display of a truck number, reweighing if requested and the terms of the attached Certification.

9. Terms and conditions of this Agreement:

A. All charges shall be due and payable upon receipt of the bill rendered, and shall be considered delinquent

thirty (30) days following the billing date. A $10.00 or 10% penalty shall be added to delinquent accounts.

B. A delinquent account shall result in denial of service until full payment is made.

C. Accounts with no activity for 12 months will be terminated.

D. The County will use available means to collect delinquent accounts, including garnishment of assets.

10. The Undersigned affirms that the information supplied on this application is true and complete to the best of his/her

knowledge and that the undersigned has the authority to enter into this Agreement. The undersigned shall notify the

County in the event there is any change in the information provided in this application.

_______________________________________________________________________________________________

Applicant’s Signature

Title

Date

___________________________________________________________________________________________________

Hanover County use only

Account Approval by:____________________ Account Number:_____________________ Date:____________________

App Solid Waste Disposal Charge Account 12/18/02

FORM1333

Application And Agreement For Solid Waste Disposal Charge Account Form - Hanover County - Public Works Department

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