HomeMy WebLinkAbout1011 HARTMAN AVEemption year: 2o F 0l.,
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date t f
Applicant`s Name:
Billing Address:
Address of Exemption
Water works Account No.: %5er 7697
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 exp tion.
ant'S 8igna
• BE COMPLETED
1 -hereby declare that we are
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
CustomeEls Name Garbage/Trash Pick�Up Contract Contract
i
CONtW T �PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office
in
Waterloo, City Ha11,
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
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 29 9323.
ltd
Date®� Signature of Authori d Company Representative
Company's Address
nn
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN T0: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow