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PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
REST_DENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA rr��
Date 24-f/,11
Applicant's Name: ,ky 1'h I Telephone No.,3N-23-)`22
B --Hing Address: 3(� 14J �,r1 o , 'q Five - �/,,1, /—, E4 5 r7 =}
Address of Exemption: 34,I q L, ry
IS, 9--- 6-1,14,- -74
Water Works Account No.: /d32 //-✓'0-Z-3 fi
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 rfoekhe xempnio
c�
r
A r tit' Signa ure
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(Wc' Rijbe rJ/f l/ kfro jl �-�/�, � hereby declare that we are
— o oany 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 Gasbags/Trash/Trash p Contract ContractIVA-
C'.r-u i �l-a u uc d LLL 12 �
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 allordinances 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 eventby calling 291-4323.
Z7 Sy
Date Signature f Aut4iorized Company Representative
Z 1 e- x-cA-5 ST .
Company's Address
0l, �(le
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
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