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Afrktg PA CAT 4cNN I - o CITY OF SAN LEANDRO APPLICATION FOR ON -PREMISE REFUSE COLLECTION yC0`6 APO R AI ED Name of Applicant Age: Address: Zip Code: List All Occupants Living on Premises: Name: Name: Name: Name: Describe Physical Handicap: Telephone Number: I declare that the foregoing is true and correct. Signed: Date: Please return this completed form to: City of San Leandro Refuse Section 14200 Chapman Road San Leandro, CA 94578 If you have any questions, call (510) 577-3452. -------------------------------------------For Office Use Only-------------------- Approved: Date: Approved: Date: Letter Mailed: Letter Mailed: Age: Age: Age: Age: