{"id":6335,"date":"2026-06-09T14:38:49","date_gmt":"2026-06-09T21:38:49","guid":{"rendered":"https:\/\/www.yakimawa.gov\/services\/utility-services\/?page_id=6335"},"modified":"2026-06-09T14:38:49","modified_gmt":"2026-06-09T21:38:49","slug":"refuse-special-haul-request-form","status":"publish","type":"page","link":"https:\/\/www.yakimawa.gov\/services\/utility-services\/refuse-special-haul-request-form\/","title":{"rendered":"Refuse Special Haul Request Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_13' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Refuse Special Haul Request<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_13'  action='\/services\/utility-services\/wp-json\/wp\/v2\/pages\/6335' data-formid='13' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Refuse Special Haul Request<\/h3><div class='gsection_description' id='gfield_description_13_1'>Before a special haul request can be conducted, you will need to fill out this form so a refuse staff member can contact you. There is a minimum charge of $25.00 for any request. If your special haul is for more than that, then you will be billed for the cost for the haul. <\/div><\/div><div id=\"field_13_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Refuse Special Haul set rates:<\/h3><div class='gsection_description' id='gfield_description_13_59'>Add specifics here for known charges: <\/div><\/div><div id=\"field_13_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_9'>Today&#039;s Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_13_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_9' class='gform_hidden' value='https:\/\/www.yakimawa.gov\/services\/utility-services\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_66\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_66'>Date Special Haul is Requested for (if not today&#039;s date)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_66' id='input_13_66' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_66_date_format gfield_description_13_66\" aria-invalid=\"false\" \/>\n                            <span id='input_13_66_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_66' class='gform_hidden' value='https:\/\/www.yakimawa.gov\/services\/utility-services\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_13_66'>Please note we do not do pickups on weekends or major holidays. <\/div><\/div><fieldset id=\"field_13_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Applicant Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_13_3'>\n                            \n                            <span id='input_13_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_13_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_13_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_13_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_13_3'>Person who is on site to rent hydrant.<\/div><\/fieldset><fieldset id=\"field_13_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Applicant Organization\/Company Name (if applicable)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_13_5'>\n                            \n                            <span id='input_13_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_13_5_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_13_5_3' class='gform-field-label gform-field-label--type-sub '>Business Name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><div class='gfield_description' id='gfield_description_13_5'>Name of business, if applicable and if it&#8217;s different than the customer name.<\/div><\/fieldset><div id=\"field_13_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_16'>Applicant Phone Number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_13_16' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div data-fieldId=\"16\" class=\"spacer gfield\" style=\"grid-column: span 8;\" data-groupId=\"026dd155\"><\/div><div id=\"field_13_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_65'>Customer Drivers&#039; License Number or tax ID number (Required)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_13_65' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_65\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_65'>Enter your tax ID number, UBI number, or government issued ID number such as a driver&#8217;s license. <\/div><\/div><div data-fieldId=\"65\" class=\"spacer gfield\" style=\"grid-column: span 7;\" data-groupId=\"c38b5c0b\"><\/div><div id=\"field_13_25\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-seven-twelfths field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_25'>Email Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_13_25' type='email' value='' class='medium'     aria-invalid=\"false\" aria-describedby=\"gfield_description_13_25\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_13_25'>Entering your email will send you a copy of this form and your bill once your account is billed.<\/div><\/div><fieldset id=\"field_13_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_13_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_13_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_13_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_13_7_1' id='input_13_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_13_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_13_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_13_7_2' id='input_13_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_13_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_13_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_13_7_3' id='input_13_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_13_7_4_container' >\n                                        <select name='input_7.4' id='input_13_7_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_13_7_4' id='input_13_7_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_13_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_13_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_13_7_5' id='input_13_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_13_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_13_17\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-two-thirds field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Street Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_13_17' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_13_17_1_container' >\n                                        <input type='text' name='input_17.1' id='input_13_17_1' value=''    aria-required='false'    \/>\n                                        <label for='input_13_17_1' id='input_13_17_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_13_17_2_container' >\n                                        <input type='text' name='input_17.2' id='input_13_17_2' value=''     aria-required='false'   \/>\n                                        <label for='input_13_17_2' id='input_13_17_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_13_17_3_container' >\n                                    <input type='text' name='input_17.3' id='input_13_17_3' value=''    aria-required='false'    \/>\n                                    <label for='input_13_17_3' id='input_13_17_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_13_17_4_container' >\n                                        <select name='input_17.4' id='input_13_17_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_13_17_4' id='input_13_17_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_13_17_5_container' >\n                                    <input type='text' name='input_17.5' id='input_13_17_5' value=''    aria-required='false'    \/>\n                                    <label for='input_13_17_5' id='input_13_17_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_17.6' id='input_13_17_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><div class='gfield_description' id='gfield_description_13_17'>If different from mailing address. <\/div><\/fieldset><div id=\"field_13_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_11'>Special Haul Location:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_13_11' type='text' value='' class='large'  aria-describedby=\"gfield_description_13_11\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_13_11'>List location\/s the request is for. Can include cross streets, property details, etc..<\/div><\/div><fieldset id=\"field_13_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Special Haul Items<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_69'><div class='gchoice gchoice_13_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Air Conditioner'  id='choice_13_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_1' id='label_13_69_1' class='gform-field-label gform-field-label--type-inline'>Air Conditioner<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Junk Pile'  id='choice_13_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_2' id='label_13_69_2' class='gform-field-label gform-field-label--type-inline'>Junk Pile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='Mattress'  id='choice_13_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_3' id='label_13_69_3' class='gform-field-label gform-field-label--type-inline'>Mattress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_69_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.4' type='checkbox'  value='Refrigerator\/Freezer'  id='choice_13_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_4' id='label_13_69_4' class='gform-field-label gform-field-label--type-inline'>Refrigerator\/Freezer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_69_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.5' type='checkbox'  value='Other'  id='choice_13_69_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_69_5' id='label_13_69_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_68\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_68'>Comments:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_13_68' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_20\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_20'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_20' id='input_13_20_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_13_20_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_13_20' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.yakimawa.gov\/services\/utility-services\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_13_20_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_13_20_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_13_20_data' name='input_13_20_data' value=''><\/div><\/div><div id=\"field_13_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">FOR OFFICIAL CITY OF YAKIMA USE ONLY<\/h3><div class='gsection_description' id='gfield_description_13_48'>All fields below are for City Of Yakima staff use only. <\/div><\/div><div id=\"field_13_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Driver: ______________________________<\/h3><\/div><div id=\"field_13_49\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SPECIAL HAUL PICKUP DATE: ______________________________<\/h3><\/div><div id=\"field_13_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SPECIAL HAUL TOTAL AMOUNT: ______________________________<\/h3><\/div><div id=\"field_13_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ADDITIONAL CHARGES OR NOTES:<\/h3><div class='gsection_description' id='gfield_description_13_47'>______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<\/div><\/div><div id=\"field_13_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">** If the form doesn&#039;t allow you to submit it due to the file size of the drivers license photo, remove the photo and submit again.**<\/h3><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_13' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_13' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_13' id='gform_theme_13' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_13' id='gform_style_settings_13' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_13' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='13' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='+ykM79JJtMbX6RDjuZsA77LkQLZmRLadtYHpRs+9VJx3nYVTdco0neg3zTqZu5paHbIeIqUSlYr6aHKMlU76SQO6MYXvv360sX\/etsZNo5nF\/PQ=' \/>\n            <input type='hidden' class='gform_hidden' 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