HomeMy WebLinkAbout3220 W 4TH STApplicant's Name
Billing Address:
No.
Address of Exemption: ��=_.._._..u........_.__ -.---
Water Works Recount No.��.����'G,�.'Ft{_—_— __..—
I request: an exemption from Garbage Lees during the current Calendar Year.. I
employ the services of a licensed trash hauler. Only thg...la -ion where the
trash hauler picks up garbage and trash w%j.k--cpqalir'-fthe exmption.
Applicant's SiUtore
TO BE COMPLETED BY LICENSED GAR13AGE AND TRASH HAULER:
(P7e) 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:
Beginning Ending
Address Location of Date of Date of
Customer's Name Garba gjTrjsh Pick -Up Cont act; C trac
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 year, we hereby agree to notify the Clerk's
Office of this event by calling 1-4323. \7
jk�� eo,
Date Sign Lure of Ant or,zed company Representative
Company's Address
/c
Garbage &'rsash liauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK 4 FINANCE OFFICE
71b MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy -- yellow