Neighborhood 40-Yard Roll-Off Container Request Form

Today's Date * Required
MM slash DD slash YYYY
Requestor's Name * Required
First Last
Requestor's Email * Required
Requestor's Phone Number * Required
Requestor or other group/organization * Required
Have you reached out to your Neighborhood Representative? * Required
If yes, please enter Neighborhood Representative's name
First Last
Neighborhood Representative's Email
Neighborhood Representative's Phone Number
1st Preferred Date * Required
2nd Preferred Date
Container Quantity * Required
Please enter a number from 0 to 5.
Each Neighborhood can receive up to five (5) roll-off containers each fiscal year
1st Container Address * Required
Street Address Address Line 2 ZIP Code
2nd Container Address (Optional)
Street Address Address Line 2 ZIP Code
3rd Container Address (Optional)
Street Address Address Line 2 ZIP Code
4th Container Address (Optional)
Street Address Address Line 2 ZIP Code
5th Container Address (Optional)
Street Address Address Line 2 ZIP Code
How many flyers or sets of flyers will you need? * Required

You may receive 50 flyers for each dumpster / roll-off container. Copies of clean-up flyers are available for you to promote in your neighborhood.
Flyers to be picked up or mailed: * Required
- Pick-up - Flyers may be picked up from City Hall
- Mail-in - Please mail to the address below
Mail-in Address
Street Address Address Line 2 ZIP Code

If mail-in option is selected above, please provide your address here.
How many temporary no parking signs will you need? * Required

You can request two signs per dumpster. Temporary no parking street signs are approved by the Santa Ana Police Department and are available for pick up at Santa Ana City Hall. You may post your signs 48 hours before the clean-up day.
By signing below, I agree and will follow through with the Neighbor-hood Dumpster Cleanup program guidelines below:
Signature of Supervising Neighborhood Dumpster Cleanup Contact: * Required
Date * Required
MM slash DD slash YYYY