HomeMy WebLinkAbout1746 WILLISTON AVEExemption year: 2019
PRIVATE HAULER GARBAGE EXEMPTION
APPLICATION RESIDENTIAL CUSTOMERS
ONLY CITY OF WATERLOO, IOWA
Date 1/12/2019
Applicant's Name: Kyle Dryer Telephone No. 319-826-5073
Billing Address:
1746 Williston Ave
Address of Exemption:
Water Works Account No.:
1746 Williston Ave
118874-544928
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.
Ap
Sigr'ture
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
BLACK HAWK WASTE DISPOSAL hereby declares 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:
Customer's Name
Address Location of
Garbage/Trash Pick -Up
Beginning Ending
Date of Date of
Contract Contract
/2/3/j/c
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 calling 291-4323.
1/3/17
Date
Signat of Authorized Company Representative
sit )Parho,t / a
Company's Address