HomeMy WebLinkAbout205 & 211 HAMMOND AVEExemption year: 2018
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
3-18-1
Applicant's Name: First Wesleyan Church
Telephone No 319/232/1271
Billing Address: 205 and 211 Harmond Ave. Waterloo, Iowa 50702
Address of Exemption: 205 and 211 Hammond Ave. Waterloo, Iowa 50702
Water Works Account No.: 7-20-1190-008568
7-20-1220-008571
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 . e exemption.
pplicant's S gnature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) Black Hawk Waste Management
hereby declare that we are
Company Name
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Address Location of
Customer's Name Garbage/Trash Pick -Up
First Wesleyan Church
Beginning Ending
Date of Date of
Contract Contract
205 and 211 Hammond Ave. 1-1-2018 12-31-18
CONTRACT 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 event that the above person discontinues service with said company
during the current calendar ear, we hereby agree to notify the Clerk's
Office of this event by calli g '91-43 3
4�r'
Date
Signature of Au orized Company Representative
811 Dearborn Ave. Waterloo, Iowa
Compan Address
Garbage"'—rash 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
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