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PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA V
Date
A licant's NaeW` I1L�1� -�� a3 �/i
pp _ Telephone No _
B illing Addres ( �C'A
Address of Exemption./-�� ail ��V ICI �_7 )� �,,�,(( Qi`�, �LZ �, ✓ �7) t! �I`Y
Water Works Account No.:
I request an exemption from Garbage Fees during the current Calendar fear. 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,
—JC���-L C C .0
Applicant's Signature
TO BE CptdPLETEU BY LZCENSED GARBAGE•' AND TRASH HAULER;
:
(We) _ ..... __— 9• hereby declare that we are
— Company Name
ra .licensed trash hauler in the City of Waterloo, Iowa, and that we pick tip
garbage and refuse atthe following location;
Beginning Ending
Address Location of Date of Date of
�Customer's Name Garbage Trash Pick -Up Contract Contract
p
NCONTRACT PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
47e understand that the above information is used by the Clerk's Office
in
Waterloo, City Ha 1.1,
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,
Ih 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 I:his event by calling 291-9323.
Date Signature of Authorized Compa iy R presen"at ive
Company's Address
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETCIRN T0: CITY CLERK 6 FINANCE OFFICE
"115 MULBERRY STREET
47ATERL00, IOl•7A 50703
City Clerk's Copy - white Customer's Copy - yellow