HomeMy WebLinkAbout(0017) K&S Disposal GOP Appliation May 2021.pdfFoRTWORTH, APPLICATION FOR
NON-EXCLUSIVE PRIVILEGE AGREEMENT
(Collection and Transportation of Municipal Solid Waste)
INSTRUCTIONS: Complete form and return to City of Fort Worth, Code Compliance Department, Solid
Waste Services Division, 4100 Columbus Trail, Fort Worth, Tx 76133
Trade Name of Annlicant
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Physical Address
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Contact Name
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Contact
Mailing Address
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Telphone Number
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Fax Number
1. Briefly describe the nature and character of the service the applicant proposes to
render. Qi5$
Pog( 0"C/ A@e&1Cf"-2
2. Estimated Number of Vehicles Operating Under this Agreement. A list
of all vehicles must be attached to this application. The list shall
include make, model, year and license plate number of all vehicles to
operate under this Agreement.
3. Do each of the vehicles listed in question 2 above have a current City
of Fort Worth Haulin Permit?
4. Applicant has attached Certificated of Liability Insurance as required in Circle One
the Non -Exclusive Privilege Agreement, Section 13 YE NO
5. Signature of the perso uthonzed by the Co pan to sign this Agreement.
Signature
Title cJnPT Date z
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For City Use Only
Privilege Agreement Number: Date Approved:
Period Covered: to Approved M&C Number:
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Dstribution: City Secretary, Solid Waste Services Division, Applicant