Confirmed _____________________________
Contractors Name: ______________________________________________________________________________
Contractors Address ____________________________________________________________________________
City: __________________________________ State _____________________ Zip: __________________________
Contractor’s Ph. # ______________________ Cell # ____________________ Fax # _________________________
Owner’s Name: _________________________________________________________________________________
Owner’s Address _______________________________________________________________________________
City: ____________________________ State: __________________________ Zip: __________________________
Owner’s Ph. # ____________________________________________________ Alt. #: ________________________
Cross Street _____________________________________________________ Map Book # ___________________
Job Date: _______________________
Time Promised: _________________
Roof Pitch:__________________
Number of Squares: ______________
Material:________________________________________________________
How Many Layers: ________________
1 story 2 Story
Save Metal: Yes No
Access: Yes No
If double handle how many
feet __________________________
H & G attached
H & G detached
House only
Apt./Condo
Industrial
Commercial
Plywood Labor Yes No
(must be on Job prior to Tear-off)
Special Instruction: _____________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
COD Price: __________________________________ Date Called In _____________________________________
WESTERN TEAR-OFF AND DISPOSAL, INC. • LICENSE #692474
P.O. Box 1794 • Glendora, CA 91740 • Tel. (626) 443-9984 • Fax (626) 443-9987