HomeMy WebLinkAbout1604 & 1614 HAMMOND AVEExemption year: a h i9
PRIVATE HAULER GARBAGE EXEMPTION APPL
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
CATION
Applicant's
Name:
HatWO Atk ( CICU T� eIephone No. -319'2440i
W
Billing Address: OL\ 4 IWLA caQi
Address
of Exemption:
Water Works Account No.:
L Lo plot `t %1..0 \i`- % \A cu M -,M Dn aQ,
119.141 501499.
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 for the exemption.
-�ivar.+h vv9e?oyrt%
Applicant's Signatu
e
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) b\oov- IC Wa J c
Company Name
a licensed trash hauler in the City of Waterloo,
garbage and refuse at the following location:
Customer's Name
CONTRACT PERIOD
hereby declare that
Iowa, and that we
Address Location of
Garbage/Trash Pick -Up
\ VA/ -1 w3
MUST COVER AT LEAST CURRENT
Beginning
Date of
Contract
CALENDAR
we are
pick up
Ending
Date of
Contract
14)1511
YEAR
We understand that the above information is used by the Clerk's Office in
Waterloo, City Hall, 715 Mulberry Street, to deteLuine 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, includingall 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
during the current calendar year, we hereby agree to notify the
Office of this event by callincf 91-4323.
Date C,Sigrjaturh of
PLEASE RETURN TO:
gt
company
Clerk's
Aut or' ed Company Representative
.P afkorv. G
Company's address
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white
Customer's Copy - yellow