HomeMy WebLinkAbout1760 WILLISTON AVE Exemption year: ZGZ-,L
PRIVATE HAULER GARBAGE EXEMPTION
APPLICATION RESIDENTIAL CUSTOMERS
ONLY CITY OF WATERLOO, IOWA
Date-
Applicant' s
ateApplicant' S Name: Grace Fellowship Church Telephone No. 319-235-9586
Billing Address: 1760 Williston Ave
Address of Exemption: 1760 Williston Ave
Water Works Account No. : 125766-508135
I request an exemption from Garbage Fees during the curs nt Calendar Year. I
employ the services of a licensed trash ha er. Only 't location where the
trash hauler picks up garbage and trash wi q fy fo the exemption.
App i n_ s Signature
TO BE COMPLETED BY LICENSEDGARBAGE AND TRASH HAULER:
hereby declare that we are
(We) ,Q r�z Etwy i f'OV\-t .VN--tJ 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
CONTFUMT �tPERIOD MUST COVER AT tEAST CURRENT� CALEN ZV
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. 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.
TLA�
Date �� j Signator of Authorized Company Repre ntative
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