HomeMy WebLinkAbout705/705 1/2 W. 3RD STExemption year: 0 / I
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
Applicant's Name:
Billing Address:
Address of Exemption:
kPiAq/5 g761_. Telephone No,
3 S /k_f G71 --tit
Water Works Account No
7,0 s i-- 7 S".
1 J
q
77
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.
'( ,co -a
/4 .
Applicant's Signatur
TO BE COMPLETEDiiBY LICENSED
�%GGAARRBAGE AND TRASH HAULER:
(We) vrrj J -h/4141 "
CompanyName
hereby declare that we are
a licensed trash hauler in the City of Waterloo, Iowa,
garbage and refuse at the following location:
and that we pick up
Beginning
Address Location of Date of
Customer's Name Garbage/Trash Pick -Up Contract
Le 4 770,1 W /A /4/7
Ending
Date of
Contract
CONTRACT PERIOD MUST COVER AI LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
Waterloo, City Hall, 715 Mulberry Street, to deteLmine 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 calling 2i1-4323.
,//43
Date
Si
n.. tur
0
of Auth ized Company Representative
d m, a (
Company's`fiddress
Garbage &Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
J-15 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow