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PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
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Applicant's Name: gOefl. LOMde Telephone No.:56-0W-6
Billing Address: 7/ Z? CeSQA c-it5 to4e4
Address of Exemption: 5-474-t
Water Works Account No.; /4 6 6 - 3? za
I request an exemption from Garbage Fees during the current Calendar Year,
employ the services of a licensed trash hauler. Only the location where the
trash hauler picks up garbage and trash wil cp.aiify for the exemption.
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App1idnt's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) Cita AokAa>blie 100)611) hereby declare that we a e
Company Name
a licensed trash hauler in the City of Waterloo. Iowa, and that we pick up
garbage and retuse at the following location:
Beginning Ending
Anirer Loca:ion of Date of Date ot
Customer's Name Garbaqe/Trasn Pick -Up Contract Contract
3-0 f! alae 71Z8 c k2cOcc,t kiet*is -I-? 1? -3i-19
CONTRACT PERIOD MUST COVER a 'VAST 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 callirr 291-4323.
Date
ed Compny epesentative
Ccipany's Ad
Garbage & Trash Haul Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK 50 FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow