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Exemption year: 2021
I PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA j
Date l ( 116 i f
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Applicant's Name: (f,- Telephone No. 510Ysl 9
Billing Address: 2 Lp,,�(a, ( -. J,,JA,4W00
Address of Exemption: bDZ (J L4 yy tw" f
Water Works Account No. :
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.
L-::ZC.
Applicant's Signature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) Rite Environmental, Inc, 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:
Beginning Ending
Address Location of Date of Date of
Customer's Name Garbage/Trash Pick-Ur Contract Contract
Anacapa Associates 1002 W 4th St, Waterloo 11/10/21
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 Muiberry 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 statemen-�s 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 ,ear, we hereby agree to notify the Clerk's
Office of this event by callin7 291-4,43.-2.13-.