HomeMy WebLinkAbout52 LAFAYETTE & 219 LANE ST2011 PRIVATE HAULER GARBAGE KXEmPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
Applicant's Name:
Billing A'
dress:
Address of Exemption
Water Works Account N
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Telephone No.
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I request an exemption from Garbage Fees during Calendar Year 20JIP.
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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Applicant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
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hereby declare that we are
Company Name
licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Address Location of
Customer's Name Garbage/Trash Pick -Up
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Beginning Ending
Date of Dace of
Contract Contract
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CONTRACT PERIOD MUST COVER AT LEAST CALENDAR YEAR 203., 5
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 calendar year 2011. 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 calendar year 2011, we hereby agree to notify the Clerk's Office of
this event by calling 291-4323.
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Date Signature of Authorized Company Representative
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Company ' s Address
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