HomeMy WebLinkAbout219 LANE ST2017 PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA c�
Date 7-',/-----749/
Applicant's Name:
l'661.015146'' ��o't.,c- i—r
Billing Address: c7 /<- w --e /1)0, Z- .S -0.)e)
Address of Exemption: 4 :2_e Cl- 0--J A ICA L-s.f, f'tf +
Water Works Account No.: 2/ A ( Ate 57/4= '.-t9 4•—' /e9/ 4 `—1 0
Telephone No. $ `(h
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I request an exemption from Garbage Fees during Calendar Year 2011.
employ the services of a licensed trash hauler. Only the location where
trash hauler picks up garbage and trash will qualify for the exemption.
c,„,d Atm
I
the
Applicant's Signatur
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
a
Company Name
licensed trash hauler in the City of Waterloo,
garbage and refuse at the following location:
Address Location of
Customer's Name Garbage/Trash Pick -Up
hereby declare that we are
Iowa, and that we pick up
Beginning
Date of
Contract
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CONTRACT PERIOD MUST COVER AT LEAST CALENDAR YEAR
Ending
Date of
Contract
4/17
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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 calendar year 2011. 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 calendar year 2011, we hereby agree to notify the Clerk's Office of
this event by calling 291-4323.,,
L317 !9
Dat
�ati�re of Aut 'zed Company Representative
��P i €rbo�aw.
Ccim an ddress
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow