HomeMy WebLinkAbout1723 ROBIN RDExemption year: 2-4) j c
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 3/1412,,,
VUI -; ' a5547-5 we - {cVn-u Applicant's Name: Telephone No. 31 - 7-31 -
Billing Address: 6'00 ,44p4NG . w/17r[ 00 5'0712'E
Address of Exemption: (41&) P-o.
Water works Account No.: I 04 3 `} _ - c 3 5 + 1o&
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.
Appli•, is Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(we) iZ,+e F-xviirortmcpl.- .I 1 le C.. 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 GarbaneLTrash Pick -Du Contract Contracq
050lrt Abr4i+S LL�. r723 R,A3•01-itok- 5121/is
CONTRACT PERIOD MOST COVER $T LAW RRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
waterloo, City Hall, 715 Mulberry Street, Co 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 acid company
during the current calendar year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.
3/(Y/�
Date
gnatur - ' uthoriz Company epreaentative
I (v DL,.vkc.n . Pt. wa-6.4o0 TA- 507o3
Company's Address �
bazbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA S0703
City Clerk's. Copy - white Customer's Copy - yellow
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