HomeMy WebLinkAbout316 RANDOLPH STExemption year: 11
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 7.- / - 1
Applicant's Name:
Billing Address:
Telephone No. 3r9 -9!c( -Melo
alb 'PA Alpin' 11 St. ca)a redo r4. WO
Address of Exemption: 3/(c. f(%(fpct St_ LA/eli-el/W ,L.q , ,CtrIp z
Water Works Account No.:
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.
t rash hauler picks up garbage and trash will qualify for the exemption.
VIA
3-� _
Ap licant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
/-v✓rill,iJ
Comany Name
hereby declare that
a licensed trash hauler in the City of Waterloo, Iowa, and that we
garbage and refuse at the following location:
Customer's Name
ay*1 a Le it? ,(7(ls ?
Address Location of
Garbage/Trash Pick -Up
JPl � ra.ei da y h sh
CONTRACT PERIOD MUST COVER AT LEAST CURRENT
Beginning
Date of
Contract
we are
pick up
Ending
Date of
Contract
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
t he 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
O ffice of this event by calling 291-4323.
Date
PLEASE RETURN TO:
n/9
Signature of Authorized Company Representative
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Company's Addreds
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow
BLACK HAWK COUNTY HEALTH DEPARTMENT
1407 Independence Avenue Sth Floor
Waterloo, IA 50703
319-291-2413
COMMERCIAL GARBAGE AND TRASH HAULER INSPECTION
Date:
Business Name: Phone: (
Business Owner/Agent: E-mail:
Address: City State .I Zip
Mailing Address (if different than above):
VEHICLE LICENSE NUMBER _ has been inspected by the Health Department and has
applied for a permit to haul garbage and trash within or through Black Hawk County to the Black Hawk County Landfill.
TYPE OF UNIT: n Packer n Pickup Truck n Dump Truck
Roll Off n Other.
GENERAL ROUTE:
CONDITION OF TRUCK:
Enclosed Type of Cover Tailgate
Body Panels
Comments:
Hauler Name on Truck
Refer also to:
1. Black Hawk County Nuisance Ordinance, Title III, Public Safety, Chapter 3 - Nuisance
2. Black Hawk County Solid Waste Management Commission Policy - Load Cover Requirements
Applicant Name (PRINT)
/
Applicant Signature
Health Department Signature
Permit Fees:
First Truck - $100.00
Each Additional Truck - $25.00
Prorated Fee:
This application has been approved by the Black Hawk County Health Department and a permit has been issued.
Expiration Date: 4. Permit Number:
Rev 03/2017