Roll Off Request
CITY OF ZEPHYRHILLS
PUBLIC WORKS DEPARTMENT, SANITATION DIVISION
39421 South Avenue Zephyrhills, FL 33542 Telephone: 813.780.0022
ROLL-OFF REQUEST FORM
TODAYS DATE: __________________________ REQUESTED DELIVERY DATE: _________________________
CONTAINER SIZE REQUESTED: _________________ 20 YARD ___________ 30 YARD ___________
LOCATION (ADDRESS) OF CONTAINER: _________________________________________________________________
CONTACT NAME (ON-SITE): ______________________________ PHONE CONTACT (ON-SITE): __________________
BILLING INFORMATION:
COMPANY OR RESIDENT NAME: _______________________________________________________________________
ADDRESS: ___________________________________ CITY: ________________________ STATE: _____ ZIP: _________
REQUESTED BY: (SIGNATURE): ______________________________ PRINTED NAME: ___________________________
DRIVER’S LICENSE NO.: ___________________________________ ACCOUNT NO. (If city resident): __________________
ROLL-OFF PRICING
DELIVERY CHARGE: (Non-Refundable) $45.00
DEPOSIT: 20 YARD (Refundable): $250 30 YARD (Refundable): $300
MONTHLY RATE: 20 YARD (30 DAYS OR LESS):$ 170.00
MONTHLY RATE: 30 YARD (30 DAYS OR LESS): $180.00
DISPOSAL FEE: 20 YARD (includes one pull): $200.00 30 YARD (includes one pull): $300.00
ADDITIONAL PULL CHARGE: $100 per pull.
Household garbage, tires, Industrial refuse or hazardous waste are prohibited from being placed in the container (additional charges may apply if prohibited items are placed in container). The City of Zephyrhills reserves the right to inspect the roll-off before removal. The City of Zephyrhills will not be responsible for property damages.
FOR OFFICE USE ONLY: CONTAINER NUMBER: ____________________________
DATE DELIVERED ON SITE: _________________________ EMPLOYEE SIGNATURE: __________________________
DATE PICKED UP: _________________________ EMPLOYEE SIGNATURE: __________________________