HomeMy WebLinkAbout107 HAMMOND CTExemption year: 1)20(5
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Applicant's Name:
Billing Address:
Address of Exemption:
Water Works Account No.:
Yti-dre
A )(
Date
-?/(12( *2120
Telephone No.
i.
/(
16?X44-5 (6Z5
I request an exemption from Garbage Fees during the r ent Calen.Ur Year. I
employ the services of a licensed trash hauler. On],i the locatiwhere the
tcasll hauler —picks up garbagzsand trash will qualify or t ex
Applicant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) B\o.Q A f iO4A)K WoLzAJQL
Company Name
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
hereby declare that we are
Beginning Ending
Address Location of Date of Date of
stomer's Name Garbage/Trash Pick -Up Contract Contract
LLC. 1O'1 ammo nb 10 Ialsi 1 a�a-cD
CONTRACT PERIOD MUST COVER AT 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 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 ear, we hereby agree to notify the Clerk's
Office of this event by call 291-4323.
Date IC/ oa-6
of Authorize Cgnpany Representative
ac-k4,00 ()I. C
Company's ress
II
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