HomeMy WebLinkAbout3833-3857 TRENT LNExemption year: 2 d /b
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
/2-2.2,-11
Applicant's Name: /Ae4' //J/ CO44 r. v, 4 S' Telephone No.3 iy' Z40-3 i
Billing Address: .3g“-- i L. Ai JA -4.101, , 1 4 5"770i
3t93,3i3S, 3Yyl, 3-1g4 3i41;731'57 T""' t
Address of Exemption: 3iecs, 3-£bs-- 3 i /C -3z4>, 3e34 >y 74(91i LA/
11LL78 SQ'/S- o -
Water Works Account No.: /lL1_75",5-/11C307'i if 03a.
11 2;Z 7(- S /iib'O J ii2.1.1 iocq.7•
17
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 ,4ill qualify for the exemption.
Applicant's Signature
/ IL* t i t~>4Ys
TO BE tC�OMPLETED, BY LICENSED GARBAGE AND TRASH HAULER:
W
(We) Cis°trt !'lu ,JC. %tA' •1'4 Q l� i 4 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 Ad
Garbage/Trash Pick -Up Contract Contract
%tie o 1 %� I I( Co .s d Q s 'y65 -r/''G LtA
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 291-4323.
►�
—7--11
Date
Si• ature of Authorized ompany Representative
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