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Time
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Location {Address or Cross Streets-
Debris Classification Estimated °f °, CYs, or Actual Wei nt
Vegetation
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White Goods
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❑ HHW -
❑ Other" See He low
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`Other Delbris Explanation
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Copy 2:
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Load Ticket Ticket No.%
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Location (Address or Cross Streets)
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}debris Classiricatior
Estimated %, CYs, or actual Wei 2h
Vegetation
❑ C &D
❑ White Goads
❑ HHW
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❑ Other* See Below
Time
Date Inspector /Monitor
Unloading • ,
OMS Name and Location
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Other Debris Explanation
Applicant
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Load Ticket Ticket No. �°� S
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Loading '3
Location (Address or Cross Streets)
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Debris Classl icatlor. Estimated /Q, CYs, or Actual Wei
Vegetation
❑ C &D
White Goods
Q HHW
❑ Other* See Below
Time Date Inspector /Monitor
Unloading iln"I / 1010, � flavl
DMS Name and Location '
"Other Debris Explanation f
Original: applicant
Copy 1:
Copy 2:
Copy I
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Load Ticket Ticket No.
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Truck No Capacity
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Time Date Inspector /Monitor
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Location (Address or Cross Streets)
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Debris Classification
Vegetation
❑
C&D
❑
White Goods
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HHW :
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Other* See Below
Time
Estimated %, CYs, or Actual Weis
Date Inspector /Monitor
Unloading
DMS Name and Locatio
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*Other Debris Explanation
Original: Applicant
Copy 1:
Copy 2:
Copy 3:
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