HomeMy WebLinkAbout3813 TRENT LN a iTiv' 'E NkUTZJi GOR3ACE EXEM ITON Al2 ,I A_'TION
RESIDENTTAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA ,j/�
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/ Applicant's Name: j�� ")j Telephone No. �
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Bi.l ling Address: � 1 �__.. �` �
Address of Exemption: ) \.
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
trash hauler picks up garbage and trash will qualify for the xemption.
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Ap '„ant's>Srgnat re
TO BE COMPLETED BY LICENSED GARBAGE A'ND'TRASH HAULER:
(We) ��� ,r \ Gr1 ryylxl�t,\ hereby declare that we are
Company Name
a licensed trash hauler in the City of Waterloo, Iovra, 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 Pic�k-U- Contract Contract
CONTRACT PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
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Waterloo, City Hall, 715 Mulberry Street, to determine eligibility for
exemption from garbage fees for the current calendar year. I, the
1 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 291-9323.
\n Date Signatu at Aut orized Company Representative
iexoL �on::��� �nU
5 Company's Address
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F, 1c
�I Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
V� PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
J 715 MULBERRY STREET
C WATERLOO, IOWA 50703
S City Clerk's Copy - white Customer's Copy - yellow