HomeMy WebLinkAbout229 CLAY ST207 PRIVATE HAULER GARBA( EXEMPTION APPLICATION
®® RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date ./ / -- a?�9 / l
Applicant's Name:
Uleie e1C
Telephone No. 6,1e- y,s-s
Billing Address: v �""ei/4-$c2c.
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Address of Exemption: 1 C(a< S' / to [ed y/Y¢ S 02a S
Water Works Account No.:
I request an exemption from Garbage Fees during Calendar Year 2011.
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)
a
hereby declare that we are
Company Name
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
Ctomer's Name Garbage/Trash Pick -Up Contract Contract
RdYiad idop j
'X' Oaf 5./-
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CONTRACT PERIOD MUST COVER AT LEAST CALENDAR YEAR X11
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.
at e of A
811
Company'
th
ized Company Representative
"ele21-67q1 /11A
ddress •
1/
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