HomeMy WebLinkAbout1205 1/2 BISHOP AVE0 Exemption year: ,ACV
Address of Exemption:
Water Works Account No.:
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
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Applicant's Name:
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Billing Address: _'o dux5S53
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202
Telephone No.
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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.
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Applica�.�'s Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
1
We 1. t. e_- /) rye hereby declare that we are
' Name
N ame
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Customer's Name
Beginning Ending
Address Location of Date of Date of
Garbage/Trash Pick -Up Contract Contract
frvuez /ilk ) 4,4 651- itzeSnala- g/site
42 cell ta-4020
CONTRACT PERIOD MUST COVER AT LEAS' CURRENT CALENDAR YEAR
"Ae 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
during the Current calendar year, we hereby agree to notify the
Office of this event by calling 291.-4323.
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Date
PLEASE RETURN TO:
Signatur of Authorize Company
company
Clerk's
_;471 jej ApAidde 5 4
Company's Address
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Garbage & mrash Hauler's Permit
Representative
1
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