HomeMy WebLinkAbout1723 ROBIN RDExemption year: ZO Zo
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OP WATERLOO, IOWA
Date 3/IS/7-0
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Applicant's Name; j TWe�ephone No. 319 - 2-2, i
Billing Address: (GO0 At -PIN& DO-. L✓A74p-IAo 5o70-
Address of Exemption: 11-o B1 u R-o
Water Works Account No.:
4'S54
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.
TO 131;y' COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) '�C.yt let. 4J,b-kj 1Ty1.= hereby declare that we are
Company Name
a licensed trash hauler in the City of Waterloo, Iowa, and that we pickup
garbage and refuse at the following location:
Beginning Ending
Address Location of nate of Date of
Customer's game Garbage/Trash pick-nt Contract Coaracy
WA5on ASr,+s LLC i7T3 bin 512.5/!8
CONTRACT PERIOD MUST COVER AT LEAST CDRR$NT CALGNDAR 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 Chia
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 eventby calling 291-4323.
Signatur Authorize Company Representative
Company's drecA c Pt- warIxrloo�TA 5A7o3
OV• Ft le.
Garbage & Trash Hauler's Permit License
(issued by Black Rawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OPFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow
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