Contact Name Name Job Title/Role: Department / Organization Email Address Phone Number Are you submitting this request for your own facility? Yes No, I’m submitting on behalf of another facility Facility Type K-12 School College / University County Building / Government Office Park Recreation / Community Center Other Please specify... Facility Name Full Facility Address Please enter the complete street address, including city, state, and ZIP code. Specific Location / Area Population Please provide the approximate number of students, employees, and/or community members served at this location. What are you requesting? Recycling Bin Hydration Station Both Replacement / Repair Other Other Number of Recycling Bins and/or Hydration Stations Please enter the quantity needed for each requested item. Waste Hauler Information? Waste Hauler Information - Select -Athens BurrtecCR&RDesert Valley DisposalPalm Springs Disposal Waste Management, Inc. Other… (self-haul, no recycling services, etc.) Goals & Involvement Please briefly describe your goals and key people or groups involved (e.g., students, staff, facilities, or community members). Additional Information Would you like to share any additional information with us? Please feel free to provide any details. How did you hear about our program? Social Media Website Newsletter Other… Please specify… Leave this field blank
