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2. Location of Service (City Name)*
4. The purpose(s) for your contact with our department today?

   (Check all that apply)

   1. Batteries
   2. Commercial Waste
   3. Construction/Demolition
   4. Domestic Animal Disposal

   1. Household Waste
   2. Livestock Disposal
   3. Waste Oil
   4. Waste Tire

   1. White Goods
   2. Yard Waste
   3. Other
6. If other, please describe:
8. Please evaluate your experience as appropriate:
10. Staff was professional and helpful?

    1. Excellent
    2. Good
    3. Average
    4. Fair
    5. Poor
11. Area clear of unnecessary debris?

    1. Excellent
    2. Good
    3. Average
    4. Fair
    5. Poor
13. Signs were easy to read and follow?

    1. Excellent
    2. Good
    3. Average
    4. Fair
    5. Poor
14. If you needed assistance, was staff available and courteous?

    1. Excellent
    2. Good
    3. Average
    4. Fair
    5. Poor
16. Please rate your overall level of satisfaction with the service you received from this department:

    1. Very Satisfied
    2. Satisfied
    3. Neither Satisfied nor Dissatisfied
    4. Dissatisfied
    5. Very Dissatisfied
18. Please note: This section is required if response is requested.
20. Name
22. Address
23. Address Line 2
25. City
26. State
27. Zip Code
29. Email
30. Phone
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field