HomeMy WebLinkAbout1621-1625 E 4TH STExemption year:
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 1- ` -i —
Applicant's Name: rtAP71L.EE �'"\C
Billing Address:
Address of
161-i ARMT 44h 'VT<
Exemption:
Telephone No.319 - 5o t ..
vaA-T Ry-00 i 5e`t63
Water Works Account No.:
I request an exemption from Garbage Fees during the current Calendar Year. I
employ the services of a licensed tras hler. Only the location where the.
trash hauler picks up garbage and tray `/11 qual'j for the e emption.
licant's Sign
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) NAt;',401 UILA4640..L_
Company Name
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
QQ
Address Location of
Garbage/Trash Pick -Up
goal
hereby declare that we are
Beginning
Date of
Contract
Ending
Date of
t
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 year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.
Date"
�,ll22
0
Signa "re gi Auth
. ized
ompa
Representative
Z I) io 1 Au? wA- do,
Company's Address
Garbage & Tras"h 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