HomeMy WebLinkAbout1712 W 4TH STExemption year: (W0/8
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
/
Applicant's Name:
Billing Address:
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Address of Exemption:
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Water Works Account No.: /f/ill .5x5072
No .J#'. .5-7g15
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's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
Company Name
a licensed trash hauler in the City of Waterloo, Iowa,
garbage and refuse at the following location:
hereby declare that we are
Customer's
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Name
and that we pick up
Beginning
Address Location of Date of
Garbage/Trash Pick -Up Contract
ria 141 4.1(-
Ending
Date of
Contract
ONTRACT PERIOD MUST COVER AT LEAST CURRENT 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
during
Office
event that the above person discontinues service with said company
the current calendar year, we hereby agree to notify the Clerk's
of this event by calling 291-4323.
/ 0/7
Date
PLEASE RETURN TO:
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Signature of Author' ed Company
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Company's Address
Garbage & rash Hauler's Permit License
(issued by Black Hawk County)
Representative
0411 , /4 O2 -
CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white
Customer's Copy - yellow