2. Company or Existing Account Name*
3. Email Address*
5. Billing Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Utility Account Number
    City of Cheney Utility Account Number
14. Last Four Digits SSN or Tax ID*
15. Date Requesting Dumpster*
17. Dumpster Service Address*
18. Dumpster Size Requested*
20. Jobsite Contact Name & Number *
22. Dumpster Placement Location*
    Please give exact placement instructions
24. I certify the above information is true and agree to responsibility and payment of account charges.
26. Signature*
27. Date*
29. A $300 deposit is required for an on-call dumpster. The deposit will be applied against the final charges and any remaining funds will be refunded.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field