HomeMy WebLinkAbout701 & 703 RANDOLPH ST t�� 2(D2") -- 2_�?J
IVAIE gRUIZp, GASB&M ELIPWTIM APPLICATION
RESIDENT , CUSTOPERS ONLY
CI'T'Y OF NAMMIM, 7th
Date
Applicant's Name: �-eIlegn&no
Billing Address: r/ a.2)S s'f TQhe
Address of Exemption:
Water Works Account No.: 197,2
a4 1A 7-Z
I request an exemption from Garbage Fees during the Trent Calendar Year_ I
employ the services of a licensed trashhauler_ Only the location where the
trash hauler picks up garbage and trash will qualify for the tion_
AL�- I zLk��
Applicant's Signature —'—
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH
HAULER-
(We) 1�Wt aZ Aereby declare that we are
Company Name
a licensed trash hauler in the City of Waterloo, Iowa, and that we pack up
garbage and refuse at the following location:
Beginning Ending
Address Location of Date of Date of
Customer's Name, Garbage/Trash Pick-Do Contract Contract
eveCll �hflQI5 w`lyh -3+ 12- -2 12-31-22-
CONTRACT
2-31-22CONTRACT PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
Waterloo, City Rall, 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.
11 -22-2
Date Signature df Authorized Company Representative
81 Ded rbocn dL
Company's Address
Garbage & 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