HomeMy WebLinkAbout528 ADRIANExemption year: g-G'A9
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 0"a-3 j- 14
Applicant's Name. (vigfir CofrL4tveiI Telephone No.3/9g(oc`0634t
Billing Address:
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Address of Exemption: irme A-Adirr, o h
Water Works Account 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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Applicant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) NO Lft Ek t,,k write a SP®Sa I hereby declare that we are
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
mark Cvincfre i
Beginning Ending
Address Location of Date of Date of
Garbage/Trash Pick -Up Contract Contract
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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
e xemption from garbage fees for the current calendar year. I, the
u ndersigned, 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
t he 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
O ffice of this event by cal g 291-4323.
Date
gnature of U' horized Company Representative
ectito 01 04)._c
Compa 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