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PRIVArs RADLEN am&= 81IS"TION APPLICATION
RESIDENTIAL CUSTCHARS ONLY
CITY OF WATERLOO, IOWA
Date
Flllclahl4t'a Nam! .Y, y y}E,t �t t� gblaphone No.J_ k 1,, 46y -,i_' IC"j
►-' .: ,,.
saaaaException: AGCe18ftL ND.:
1 request an exemption from Garbage Pees duringthe currant Calendar Year. I
employ the services of a licensed trash hauler. Only .the location where the
trash hauler picks tip garbagft and trash Will qualify:. for tho wxampt.ion.
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gant'.s ffi uzq 5 �,ar,E,fil
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH SAQLERz `` <x c
IWO) -. QiL?,1ili��� (__ � ...,.. hereby declare that we urn
Company. ,'.V,a
a licensed trash hauler in the City of Waterloo, Iowa, and that we pick up e
garbage .and refuse at the following location: : r
.Beginning Ending x10
Address Location of Data of Date of
Custamer's HCAC Garbage/Trash ..j(g / C�,EanF �
���',�1LTk�.IL• dam' L /�r __�. .�...y:.J..M.', SRI !�.fp�.l.. II rs'
COMILACT PERIOD MUST COVER b.I,= CURRENT CALENBAR YEAR
�R`y Pr
We understand that theabove information is used by the Clark's -Office in
Waterloo, City 'Hall, 715 MulberryStreet, to determine eligibility for
axaapt.lon from garbage fees for the current calendar year. I, the
undersigned, declare :under penalty of :perjury that I have "gained this
claim, including all statements and above schedule, and to the best of m11 1
MB
knowledge and belief, it is a TRUE, CORRECT A, comrl, %E clefs:, and that I
agree to comply with all ordinancoe and policies of the city of Waterloo and
the :Black Hawk County .:Solid Waste Commission..
In the event that the above person discentinuas service with said C01"ny
during the current calendar yoar, we hereby agree to notify the Clerk's ..,x
Office of this avant by calling 291-4323.
Data .aV�f6ai�-
y�Repra.s..e-.nt atva,*��k , ��
aapani'/}�]`r^asa
Gar gq i Tram Ha ors t cense ' �
(issued by Black Rank county), a' _
Praus RETURN ?C: CITY CLERK [ rINAWCB OFFICE a
715 PRJs,BBRRY &MUT ;
NATY.RLOO, IOWA 50703 r
City Clerk'a Copy white CustaikWa Copy ye'llaw,