Request for Waste Fill

   Town Of Durham
Public Works Department
      1099 Royalsborough Road                                  Tel: 207-353-3281
        Durham, Maine 04222                                    Fax: 207-353-3283

Request for Waste Fill I hereby request waste fill from the Town of Durham, and agree to the following conditions if and when the said waste fill is given to me:

1. I do hereby permit and allow the Town of Durham, its agents and employees, and any and all private trucks and operators working for the Town, to dump waste fill on my property.

2. I hereby agree to assume all liability for damage which may be cause to my property, or to adjoining property in the process of dumping, which may result from the dumping of said waste material in the area requested by me, and I will not hold the Town of Durham, its agents, or employees, or any private operator working for the Town of Durham, responsible or liable for any damages or injuries, or death, which might result from or occur in the course of dumping said waste materials; and I further agree to defend and hold harmless the Town of Durham for any money or expense, including but not limited to attorney fees, and cost that the Town of Durham might incur as the result of property damages, personal injuries, or death resulting to any person or property in the course of dumping said waste material.

3. I do hereby agree to keep the proposed dumping area clear for trucks to enter without obstruction, and without causing damage to said trucks.

4. I do hereby agree to assume all responsibility for any licensing or permitting that may be required.

5. It is further agreed and understood by myself that this request does not guarantee receipt of a certain amount or type of waste material being hauled and dumped on my property. The type of waste materials depends upon availability.

6. I further agree to accept said waste material at no cost to myself, and will not offer or give any money to the said town officers, employees, or agents, or to any private truck owner or operator working for the Town, in payment of said waste material.

The above conditions have been read by me and are clearly understood, accepted and agreed to.

Owner: ________________________________ Address: _____________________________________

Signature: ___________________________________            Date: _________________________________

Phone Number: ___________________________________

Approved by: _________________________________________________

Please provide sketch on the back of this form as to where you want your fill delivered. Please include where your septic tank, leech field, well, etc. is located, in relation to fill area.