BACKDOOR SERVICE

WASTE COLLECTION ASSISTANCE PROGRAM

Instructions: Please print clearly. Fill out this form and attach your physician’s certification of your need. Return form to: Pinellas County Utilities, Solid Waste Department

3095 114th Avenue North

St. Petersburg, FL. 33716

or fax to (727) 464-7713.

Last Name: / First Name: / MI:
Street Number: / Street Name:
City: / Zip Code:
Phone Number: / Pick up Days:

I hereby attest that I have a disability that prohibits me from placing my waste at the roadside or alleyway for normal collection. I also certify there is no other household member that could carry a waste container to the roadside.

I understand that a Doctor’s Certificate will be required stating that I am not able to move a waste container to the roadside for collection.

I understand that I am authorizing the waste hauler to enter my private property to collect my residential waste from my backdoor at each regularly scheduled pickup. I further understand that my waste containers or bags may not exceed forty-five gallons or fifty pounds, and yard waste will be containerized, bagged, or piled not exceeding four (4) feet in length and four (4) inches in diameter.

I also understand that if at any time the validity of the application is in question, the District Representative may require a new Doctor’s Certificate or proof that I still meet the requirements as set forth in Pinellas County Code. I further understand that this is a service not a right, and that the District may discontinue this service at any time if my statements are found not to be accurate or to meet the District’s requirements as they may be amended.

X

SIGNATURE DATE

District Use Only

DOCTOR’S CERTIFICATE ATTACHED AND DATED: / YES / o / NO / o
APPLICATION: / APPROVED / o / DENIED / o
EFFECTIVE DATE: / ZONE/ROUTE:
DISTRICT REPRESENTATIVE:
Signature

Revision 12/2006