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2. First Name*
3. Last Name*
5. Address *

   (Please indicate the address where the pickup is taking place)

7. City*
8. State*
9. Zip*
11. Email Address*
12. Phone Number*
14. Item
    Household Debris Collection Amount
15. Amount*
16. Quantity
17. Shipping Cost
19. Taxable
Leave This Blank:


20. Calculate Totals Proceed to Checkout

* indicates a required field