Infrastructure Services
Shire of YarraRanges
P.O. Box 105
LILYDALE VIC 3140
Telephone: 1300 368 333
Application for Resident Funded Dust Suppressant 2017/18
Applicant’s Name: ......
Applicant’s Address:......
......
Home: ...... Work: ...... Mobile: ......
Is this application made on behalf of a group of residents YES NO
If YES, please provide details of other contributors to this application :Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Name / Address
Road to be treated......
Section of Road Requiring Dust Suppressant (from and to details)
......
......
Treatment Length: ...... Payment Enclosed: ......
(must be 100 metres or greater)(payment to be sent with application)
Please draw a plan of the road (on the reverse side of this application form) clearly showing the section of road to be treated (using references such as house numbers, driveways, fencelines, road features, etc. to enable ready identification of the section to be treated)
FOR CASHIER USE ONLY
To be receipted to cost centre: 900325-1612
Receipt and application paperwork to be forwarded to the Infrastructure Services Department–AS SOON AS POSSIBLEfor processing.
Plan of Road (showing section of road requiring treatment)
Any further information relating to this application: -
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......
......
......
......
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Cost:-
100 metres - $340 / 200 metres - $680 / 300 metres - $1,020 / Etc.Disclaimers: While every effort will be made to ensure the best results for residents as part of the resident funded Dust Suppressant option, weather and other conditions may affect the performance of the product. No refunds will be provided or additional treatments undertaken. The Dust Suppressant product will only be effective for period of up to 8 weeks subject to suitable weather and site conditions and the effect of the product diminishes with time from the day of application up to the end of the 8 week period.
please ensure that all details on this formarecompleted
and returned with payment to yarra RANGES COUNCIL BY
5.00pm On FRIDAY 10 NOVEMBER 2017
(NOTE: Late Applications not Accepted)