HomeMy WebLinkAbout1746 WILLISTON AVEExemption year:4L
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 2 �m6Cr 078' Aooxia
Applicant' s Name: QC-P. ,BIr,.44 rL i c6U ire k. Telephone )No .31 f. c73SJ 9
Billing Address: 1 T41p W 1. 1 1%,S*ph 4ye, _ t0etw e `loo _ X4 *5
Address of Exemption: 1_ y
Water Works Account No.:
S�
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 tra will ualify for the exemption.
MIT
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We)
Company Name
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 Garbace Trash Pick Contract Contract
(�SS�VC e 1 7 O cw i ,s N
leMU
h e�ll�'l"� Ji'1�roS W, 1741e . +21 12-3/-)
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
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
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 the current calendar year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.,
0
-Z�- Z n d1JJJ4 tr 1pokkolivon
Date Signature of uthorized ompany Representative
Ie & 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