HomeMy WebLinkAbout1760 WILLISTON AVEExemption year: 2019
PRIVATE HAULER GARBAGE EXEMPTION
APPLICATION RESIDENTIAL CUSTOMERS
ONLY CITY OF WATERLOO, IOWA
Date 1/12/2019
Applicant's Name: Grace Fellowship Church Telephone No. 319-235-9586
Billing Address:
1760 Williston Ave
Address of Exemption:
Water Works Account No.:
1760 Williston Ave
125766-508135
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.
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) �l®��V rL�l7V(/UTl
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 Name ,� Garbage/Trash Pick -Up Contract Contract
60 ce-
) lied AA/
/1(1
21/3/11
RAC PERIOD MUST C VER T LEAST CURRENT ALENDAR YEA
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 call 291-4323.
//
Date /V/ 9 ignature of Authorized Company Representative