HomeMy WebLinkAbout1746 WILLSTON AVE Exemption year: 20;72
PRIVATE HAULER GARBAGE EXEMPTION
APPLICATION RESIDENTIAL CUSTOMERS
ONLY CITY OF WATERLOO, IOWA
Date
7Address
Name: PA-0 �-A6E- ( ArE tl�p ,fii Telephone No.
ss: 1746V�illistonAve
xemption• 1746 Williston Ave
Water Works Account No. - 118874-544928
I request an exemption from Garbage Fees during the current Calendar Year. I
employ the services of a licensed trash hauler. my the 1 cation where the
trash hauler picks up garbage and trash wiliqpE y for the exemption.
Applict ' gnature
TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HAULER:
hereby declares that we are 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
t�G (t �5-� _Z/2-34Z
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.
Date Signatu of kuthorized Company Representative