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Back Door Waste Collection Form

  1. City of Belmont Solid Waste Division Verification Form for Physically Disabled Persons

    ( to be completed by attending physician)

  2. It is my professional opinion that his/her inability is permanent. ________ It is my professional opinion that his/her inability is temporary._________ The temporary inability is anticipated to end _____________

  3. Please Type or Print

  4. Resident's Statement

    (To be completed by resident requesting service)

  5. In accordance with the physician's verification above, I am physically unable to transport my household refuse to the curb for collection. I further verify that there is no able-bodied person regarding at my residence who is capable of transporting my refuse to the curb for collection.

  6. Leave This Blank: