HomeMy WebLinkAbout216 HAMMOND AVEExemption year:
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date �Jo/
Applicant's Name:
Billing Address:
Address of Exemption:
Water Works Account No.
I request an exemption from Garbage Fees during
employ the services of a licensed trash hauler
trash hauler picks up garbage and trash will -
Applicant's
Tele hone No.
current Calendar
y he location lw
for e exempt
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
(we)
Year. I
ere the
on.
�cW LIrV 15� � hereby declare that we are
—many 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 Contract Contract
4AQAVJZk 21te )UMM I d(f�
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 WasteCommission.
In the
during
Office
event that the above
the current calendar
of this event
by
ate
person
discontinues service with
said
company
year,
we hereby agree
to notify
the
Clerk's
�1
3e & Trash Hauler' Permit LJ
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
cense
City Clerk's Copy - white Customer's Copy - yellow