City of Victoria Form Center

2. CONTACT INFORMATION
4. First and Last Name*
5. What is your relation to the person on the water bill?

   1. Self

   1. Other
7. Street Address*
8. Is the collection location the same as the billing address?

   1. Yes

   1. No
10. Contact Number*
11. Email*
13. Type of Request*
    -- Select One --Schedule Large Item / Tree Limb CollectionReport A Missed CollectionRequest A Cart Number or Additional CartApply For The Waiver ProgramMy Address Is Missing From The Service Search (submit form)
14. How did you hear about the online request form?*
    -- Select One --City Department / WebsiteFacebookWord of MouthOther
16. REQUIRED FOR LARGE ITEM / TREE LIMB COLLECTION
18. This request is for:

    1. Tree Limb Collection Area 1
    2. Tree Limb Collection Area 2
    3. Tree Limb Collection Area 3
    4. Tree Limb Collection Area 4
    5. Large Item Collection
19. Large item collection, please list the items being collected:
21. There is a possibility of additional charges that may be applied to your water bill.

    * Tree Limb In-cycle collection charges: If the trucks are in your scheduled residential service area, the driver will collect up to 6 cubic yards (4' x 4' x 10') per quarter at no cost. Any collections exceeding 6 cubic yards will require a $1.50 per minute loading fee. * Out-of-cycle collection charges: If the trucks are not in your scheduled residential area, then there will be a $20 service fee plus $1.50 per minute loading fee. * Large Item Collection: If the large items to be collected exceed 6 cubic yards (4' x 4' x 10'), then you will be charged $1.50 per minute loading fee. * If you have already used your 2 free large item collections per year, then you will be charged a $20 service fee plus $1.50 per minute loading fee.

    1. Yes, I have read the information and understand the charges. I approve.
    2. No, I do not approve charges.
23. REQUIRED FOR MISSED COLLECTION
25. What type of collection was missed
    -- Select One --GarbageRecyclingYard Waste
26. Is the missed collection still placed at the curb?
    -- Select One --YesNo
28. REQUIRED FOR CART NUMBER OR ADDITIONAL CART REQUEST
30. Please send me my cart numbers for:

    1. Recycling Carts

    1. Garbage Carts
31. I would like additional carts for:

    1. Recycling Carts

    1. Garbage Carts
33. I understand by requesting an additional garbage or recycling cart, I approve charges of $6.50 per month with at least a one year commitment.

    1. Yes, I have read the information and understand the charges. I approve charges.
    2. No, I do not approve charges

    We recommend placing carts on either side of the driveway, if possible, to ensure compliance with the rule of 5' of clearance.

35. REQUIRED FOR WAIVER PROGRAM APPLICANTS ONLY
37. Reason for Requesting a Waiver
38. Emergency Contact Daytime Phone Number
40. Emergency Contact First and Last Name
41. Relation to Emergency Contact
43. Waiver Comments / Additional Information
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field