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HomeMy WebLinkAbout1261 & 1271 BLACK HAWK RDExemption year: \© PRIVATE HAULER GARBAGE EXEMPTION APPLICATION RESIDENTIAL CUSTOMERS ONLY CITY OF WATERLOO, IOWA Date y -2.v 1 1 Applicant's Name: Billing Address: 1 e Qru L' ,' e .S Telephone No. 30-910% `vis 415 Lai -. r Ct.;cae, GLAtur3 / t Address of Exemption: 1 jco,.C,J__\ncouyfV- 0,, e -•t kisZ, \ 50 Water Works Account No.: � �.'i1-2J.i1 It �ct1 �- & I I 12 1* - W4I'Id_51 3-15 I request an exemption from Garbage Fees during the current Calendar Year. I employ the services of a licensed trash hauler. Only the location where the. trash hauler picks up garbage and trash will qualify for the exemption. Applicant Signature TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HA LER: (We) Company Name reby declare that we are a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up garbage and refuse at the following location: Address Location 0Y - Customer's Name Garbage/Trash Pick -Up pa,\mer-- h (1)1 1 I CONTRACT PERIOD MUST COVE_ EAS Beginning Ending Dat:: of Dare of Contract Contract CALENDAR YEAR We understand that the above information is used by the Clerk's Office in Waterloo, City Hall, 715 Mulberry Street, to determine eligibility for exemption from garbage fees for the current calendar year. I, the undersigned, declare under penalty of perjury that I have examined this claim, including all statements and above schedule, and to the best of my knowledge and belief, it is a TRUE, CORRECT AND COMPLETE claim, and that I agree to comply with all ordinances and policies of the City of Waterloo and the Black Hawk County Solid Waste Commission. In the event that the above person discontinues service with said company during the current calendar year, we hereby agree to notify the Clerk's Office of this event by calling 291-4323. Date ) 1 Signa'Eure of Author zed Company Representative 7\.1 Company's ress Garbage Hauler's Permit License (issued by Black Hawk County) PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE 715 MULBERRY STREET WATERLOO, IOWA 50703 City Clerk's Copy - white Customer's Copy - yellow