HomeMy WebLinkAbout103 HAMMOND CTExemption year:
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
Applicant's Name:
Billing Address:
Address of Exemption:
Water Works Account No.:
I request an exemption from Garbage Fees duri c
employ the services of a licensed trash haul r.
trash hauler picks up garbage and trash wit qu
!e Curren Calendar Year. I
my the ocation wherethe
fy ia-V hl exemption
TO BE COMPLETED BY L`I�C�ENNSED GARBAGE AND TRASH HAULER:
(We) f hi& NoI(,�.� (, s4me D i S pQSo► hereby declare that we are
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 C Garbage/Trash Pick -Up Contract Contract
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
exemption from garbage fees for
undersigned, declare under penalty
Street, to
the current
of perjury
determine eligibility
calendar year. I,
that I have examined this
for
the
claim, including all
knowledge and belief,
statements and
it is a TRUE,
above schedule,
CORRECT AND
and to the best of
COMPLETE claim, and that
my
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 calling 291-4323.
7 /5%a1
Date Sign�4fure of Authorized Company Representative
M
l I UPdY bo
Company s Address
III
j
e & `trash Hauler ` s Permit L�
(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