HomeMy WebLinkAbout109 HAMMOND CTExemption year: a'919
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
Applicant's Name:
Billing Address:
Address of Exemption:
Water Works Account No.:
qw6//7
Telephone No.
I request an exemption from Garbage Fees during the curr-- Ca dar Ye. . I
employ the services of a licensed trash hauler. Only e 1• ation the
trash hauler picks up garbage and trash will qualify 'or e exem
L} ate
Appli nt's Signature
TO BE COMPLETED BY LICENSEDD GARBAGE%]AND TRASH HAULER:
(1 P ,?'S OFFICE J Oj � � was
Company Name
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
90 9
hereby declare that we are
Beginning Ending
Date of Date of
Contract Contract
I� \amt `)1119
Address Location of
Customer's Name Garbage/Trash Pick Up
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 calling1'91-4323.
Date
ature of Author zed 2?npa yy Representative
� ative
�l 1 /\ O for I__a0
Compa Address
L `
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