The following forms need to be filled in and submitted to the Recycling Center prior to bringing your waste in for disposal. This allows the staff to be prepared for the various materials that will be dropped off and to help you with managing any wastes that do not need to be brought in. When you have completed the form you may either mail it or fax it to the Recycling Center where our staff will review the information and contact you with further instructions. Be sure to check out the pages found on the top bar for more helpful information.

     Dickinson Recycling Center, 2260 220th Street, Milford, IA. 51351  (712) 338-2549            

Applicants Name: ___________________________________________________________

Applicants Mailing Address __________________________________________________

City, State & Zip ___________________________________________________________

              Day Phone # ____________________                 Evening Phone # ________________

                                           Email ____________________________________

Do the HHMs you are bringing in for disposal originate from your property     ____yes  ____no

If above answer is no, who are you assisting with their HHMdisposal  needs?                                _______ Relative               ______ Friend                      Other ____________________

Address of HHMs to be disposed of - if different from Applicants:

Address ____________________________________________

City, State & Zip ______________________________________

The HHMs being disposed of originated from a household found in:

____ Arnolds Park   ____ Lake Park      ____ Milford        ____ Okoboji      ____ Superior

____ Orleans             ____ Spirit Lake    ____ Wahpeton   ____ West Okoboji  ____ Terril

____ Armstrong        ____ Unincorporated Area of Dickinson County      Other ___________

                LIST ALL TYPES OF HHMs THAT YOU WANT TO BRING FOR DISPOSAL                                      MATERIALS NOT LISTED WILL NOT ACCEPTED

#1   LATEX PAINT         (disposal cost of $2 per container: max of 40 gal per. appointment)   Quantity (# of  pounds, etc.) __________    Container Type (jar, bag, can, etc.) ____________ Container Conditon:  _____ good     _____fair    _____ poor

#2   OIL PAINT (solvent based)               (max of 40 gal. per appointment)                            Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#3   MOTOR OIL                (max of 20 gal. per appointment)                                                     Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#4   ANTIFREEZE                                                                                                                            Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#5   AUTOMOTIVE/LEAD ACID BATTERIES                                                                          Quantity (# of  pounds, etc.) __________    Container Type (jar, bag, can, etc.) ____________ Container Condition:  _____ good     _____fair    _____ poor

continue listing your materials

#6 _____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#7 _____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#8 _____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#9 _____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#10_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#11_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#12_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#13_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#14_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#15_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#16_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#17_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#18_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#19_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

#20_____________________________________________________________________    Quantity (# of pounds, etc.) ___________   Container Type (jar, bag, can, etc.) ____________ Container Condition: _____ good    _____ fair    _____ poor

I hereby attest that the above information is true and that the HHMs that I am bringing in for disposal originated from a private residence and that the HHMs have been correctly identified, to the best of my ability.

___________________________    ________________________   ___________________ signature                                                        printed name                                      date

Upon filling out this form, send it back to the Recycling Center for our review and approval. You may send your completed form either by mail, fax, in person or by email.

                  Dickinson Recycling Center <> 1924 240th Street <.> Milford, IA, 51351                         Phone/Fax: (712) 338-2549                                                       dickinson@qwestoffice.net

Please give us several choices that are convenient for you to bring your HHMs in for disposal. We will try to accommodate your schedule when setting an appointment time.

1st option:         date __________________                  time ____________________

2nd option:         date __________________                  time ____________________

3rd option:         date __________________                  time ____________________

4th option:         date __________________                  time ____________________

5th option:         date __________________                  time ____________________