HomeMy WebLinkAbout205 HAMMOND AVEExemption year: 2021
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date 4-6-2021
Applicant's Name: Wes eVan Ch 7rm Telephone no.232-1272
Billing Address: 205 Hammond Ave. Waterloo IA 50702
Address of Exemption: 205 Hammond Ave; 205 Hammond Ave. Apt A
water Works Account No.: 108261-503626; 108264-503628
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.
Signature
Rev. David Bass
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(We) �(a I- A);; . WaSk� b E CA �ereby 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 -Up Cont act Contract
Av z z
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 h reby agree to notify the Clerk's
Office of this event by calling 291-4323.�
'�i�gn.�fXfe of Authorized Company Representative
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN T0: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow