1

Date of Application

 *

Date of Application

2

Business Name

 *

Business Name

3

Street Address including City, State, Zip Code

 *

Street Address including City, State, Zip Code

4

Mailing Address including City, State, Zip Code

 *

Mailing Address including City, State, Zip Code

5

Business Phone Number

 *

Business Phone Number ext.

6

Owner's Name

 *

Owner's Name

7

Owner's Phone Number

Owner's Phone Number ext.

8

Primary Contact Person

 *

Primary Contact Person

9

Primary Contact Phone Number

 *

Primary Contact Phone Number ext.

10

Primary Contact Email Address

Primary Contact Email Address

A commercial customer shall pay disposal fees for the commercial waste transported to the Northwest Solid Waste Management Facility located at 14450 Landfill Road, Brooksville, Florida 34614. The amount paid will be based on the type and tonnage of waste.

To establish a commercial charge account, a deposit equal to one (1) month of disposal charges is required. The account will be reviewed annually. A sum equal to the monthly average of landfill fees for the past twelve (12) months shall be maintained as a deposit. Said deposit shall be adjusted annually to reflect increases in landfill rates and usage.

Disposal fees are due on the twentieth (20th) day of the month for the preceding month's charges.   Late charges will be assessed on accounts not paid within sixty (60) days of the billing date. The late charge will be determined based upon the policy of the Hernando County Finance Department.

County reserves the right to decline to establish a commercial charge account for any applicant for any reason. County further reserves the right to refuse disposal to an applicant if applicant has unpaid disposal fees outstanding. Further, County may revoke the charge account privileges of applicant upon thirty (30) days written notice sent to customer's last location as indicated on application or any amendment thereto. Customer is responsible for notifying County of any change of circumstances or change of address or telephone. If County is required to initiate legal proceedings to collect any debt owed to it by applicant, or to turn the debt over to an outside agency for collection, applicant agrees to pay all costs of collection including reasonable attorney's fees.

A written request is required to close the account. If account is in good standing, the deposit will be refunded at that time.

YOUR SIGNATURE MEANS THAT YOU HAVE READ AND ACCEPT THE TERMS OF THE ABOVE CONTRACT.

11

Applicant is the Owner or Owner's Agent

 *

Applicant is the Owner or Owner's Agent

Owner

Owner's Agent

12

Applicant Signature

 *

Applicant Signature

13

FOR OFFICIAL USE ONLY:

ACCOUNT NUMBER______________________________________

DATE ENTERED__________________________________________

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1