HomeMy WebLinkAbout223 W 10TH STExemption year: 2U2-D
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 21 ,14
Applicant's Name:
Billing Address:
V)A01.2-Si14 C/ #(.1 $ Telephone No.(.1 z�� 35l/
216 t) IFL WATO (I
Address of Exemption: 22 hL lb*' 1 to F - O Ii 5 L 7C')--
Water Works Account No.: I(q5<2-5-O$CO`j
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.
Ap licant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
( We ) 4usi 1> v4 SP.t .
hereby declare that we are
Company Name
a licensed trash hauler in the City of Waterloo, Iowa,
garbage and refuse at the following location:
Customer's Name
4P2 Cikk C e 44e
Address Location of
Garbage/Trash Pick -Up
2v6 ki-1 `�sT 10T ;b iPr
CONTRACT PERIOD MUST COVER Al LEAST CURRENT
and that we pick
Beginning
Date of
Contract
0-o
up
Ending
Date of
Contract
12 I k12 0
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 calli ' 291-4323.
31. pow
Date
gnat r Representative
e of Aut ized Company
St( I orb° M. c
Company s Address
I I
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