HomeMy WebLinkAbout111 REBECCA LANEExemption year: aCA CI
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 16- a 3- l
Applicant's Name:
Billing Address:
Address of Exemption:
Water Works Account No.:
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Telephone No.
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I request an exemption from Garbage Fees during the current Calendar Year. I
employ the services of a licensed trash hauler. Only the lat-en—where the
trash hauler picks up garbage and trash will qua if or t- exemption.
A•plicantSignature�
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
Sim< Wvv4e DispcsAl
Company Name
hereby declare that we are
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Address Location of
Customer's Name Garbage/Trash Pick -Up
t»n Weqerc
Beginning Ending
Date of Date of
Contract Contract
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Rebecca unlo°. I-1-lq la -X1.1 -q
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 :ander penalty of per3ury that I have examined this
claim, including al. tements 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 , calnaar year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.
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Date
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Signature of Authorized Company. Representative
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Company's Address
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Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: ''47'CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white
Customer's Copy - yellow