HomeMy WebLinkAbout107 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.: L (
Telephone No.
I request an exemption from Garbage Fees during the
employ the services of a licensed trash hauler. O
trash hauler picks up garbage and trash will quali2.
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER: 0.
(We)
tion
Year. I
her the
on.
1r�C� {�Cl.�� � ��� �)��ereby declare that we are
Compan alame
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up
garbage and refuse at the following location:
Address Location of
Beginning Ending
Date of Date of
Customer's Name Garbacre/Trash Pick -Up ontract Contract
LANJYo+�5, 1 �� �yr, n1crn�� i Z 1��
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, and to the best of
CORRECT AND 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 disc
during the current calendar year, we h
Office of this event by ca11�91-4323.14
Date
inues service with said company
�( agree to notify the Clerk'
s
of Autnorizea Company representative
3e & 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