Recycler's Exclusion Declaration

2. Property Address (Location)*

   Street Address & Zip Code

3. Zip Code*
4. Type of Location*
   -- Select One --BusinessResidential
6. Property Owner Name*
7. Property Owner Phone Number*
9. Tenant Name*
10. Tenant Phone Number*
12. Mailing Address*

    Street Address & Zip Code

13. Email Address*
17. How much non-recyclable/non-compostable waste do you generate each week?*
    -- Select One --< 1 gallon or pound1-2 gallons or pounds3-4 gallons or pounds5-6 gallons or pounds7 gallons or pounds8 or more gallons or pounds

    Answer question in low estimate of volume (gallons) or weight (pounds).

19. Do you store this waste in a watertight container until it is properly disposed of?*
    -- Select One --YesNo
21. What do you do with the solid waste that you generate?

    Please state where/how each type of solid waste is to be legally recycled, composted or disposed.

23. Glass & Plastic Containers*
24. Aluminum, Bi-Metal, Aerosol Containers*
26. Newspapers & Magazines*
27. Catalogues & Phone Books*
29. Junk Mail, Office Paper, Envelopes*
30. Cardboard*
32. Large Bulky Items (furniture, appliances, etc.)*
33. Household Hazardous Waste, Paints, Oil, Pesticide Cans, etc.*
35. Food Waste, Organics*
36. Yard Waste/ Green Waste*
38. Non-Recyclable Food Containers*
39. Non-Recyclable Items, Plastics, Styrofoam, etc.*
41. Other Items or Disposal Information
45. Declaration

    I declare that the information I have provided on this Recycler’s Declaration is true and accurate, and that I legally recycle, compost and divert out of the landfill virtually all of my household’s solid waste in conformance with Eureka’s Solid Waste ordinance. I agree to continue disposing of my household waste items in the manner I have described on this Declaration, and declare that no unsanitary condition, hazard to health, or public nuisance will arise upon the premises owned, managed or controlled by me if it is not provided with collection and disposal services.

    I understand that any significant deviation from what has been declared on this document may be a considered a violation which can result in the revocation of this exclusion, and/or result in the assessment of penalties under Eureka Municipal Code section 10.99.

47. Solid Waste Information*

    1. By checking this box, I affirm that the above information regarding my solid waste disposal is true and correct.
49. Signature of Property Owner or Tenant*
50. Today's Date*
52. Birthday of Property Owner or Tenant*

    (Required information for tracking software)

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field