Clean Up Report

Clean Up Date (Required): Month January February March April May June July August September October November December    Day Year 2012 Organization Name (Required): Contact Name (Required): Participant/Organization Address (Required): Postal Code (Required): Participant/Organization Phone Number (Required): Adoption Program: Adopt-a-Street Adopt-a-Park Adopt-a-Trail Adopt-a-Stream Number of Participants: Number of Hours (Required): Number of Bags Collected (Required): Total Weight of Garbage (Required): Were there any injuries?: Yes No List any Incidents: Other Observations: Were there any unusual items?: Garbage pickup required?: Yes No Security Code (Enter below): Submit     Clear Form

Any personal information collected on this form will be managed in accordance with the Freedom of Information and Protection of Privacy Act. Direct enquiries, questions, or concerns regarding the collection, use, disclosure, or safeguarding of personal information associated with this form to Freedom of Information and Protection of Privacy Coordinator, 20338 – 65 Avenue, Langley BC V2Y 3J1 604.533.6004.