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HomeMy WebLinkAbout229 CLAY STExemption year: 2624 PRIVATE HAULER GARBAGE EXEMPTION APPLICATION RESIDENTIAL CUSTOMERS ONLY CITY OF WATERLOO, IOWA Date gig Applicant's Name: Telephone NO0/9-00 Billing Address: C � � ) I"/ o Address of Exemption: An d �p 5402-e±- )(12.1 d4©o Water Works Account No.: /6d 5 7 '_" 3_% 3 8?q 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 _ lify for t exemption. Applicant's Signature TO BE COMPLETED BY LICENSGARBAGE AND TRASH HAULER: \t) (We) Company Name h�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: Beginning Ending Address Location of Date of Date of Customer's Name Garbage/Trash Pick -Up Contract Contract (V,D1 S3C\ Dak C • SA— VA —t ID-- 1—teK, CONTRACT PERIOD MUST COVER A 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 year, we hereby agree to notify the Clerk's Office of this event by calling 291-4323. Date Signature of Auth zed Company Representative 1 � Company's Address Garbage & Trash 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