HomeMy WebLinkAbout709 & 709 1/2 RANDOLPH ST xxtaan year:2c�22-
1VA OW APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date ;. — CR U v� f
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Applicant's Name: �A rl)d JC�/'L/?�- ' A
Billing Address: .1�5 x.7.524 St f'�/i2 ester rte- 17A �� 7
Address of Exemption: O tL
Water Works Account No.: 1 7 3 9,q
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.
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Applicant's Signature
TO BE COMPLETED B,Y' LICENSED SG�ARBAGE AND TRASH HAULER:
(We) p1C�� l�AS� hereby 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 Contract Contract
pAof aFroc-L (0 L,-� Si� 3+ 1 z-1 -z 1 12 31 a a
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_ 1, 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 I
Date Signature of Authorized Company Representative
81 I Dea+-b0-n "i,-K
Company's Address
Garbage'& Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK S FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow