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PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOCa IOWA
Cate March 9. 2022
Applicant's Name: First UnitedMettiodist Church_ Telephone Nc._319,216,70811
Billing Address: _614....13andolph street, Water1ctO.A0702
Address of Eernpr 614 Randolph Street. Waterloo, IA 50702
Water Works Account No.: 10/3917503268
I request an exemption from Garbage Feen during the current Calendar Year. 1
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.
CApplica$
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TO BE COMPLETED BY LICENSED GARBAGE AND TRASH HASLER:
(1e) Rite Environmental
company Name
a licensed trash hauler in the City of Waterldo, Iowa, and that we pick up
garbage and refuse at the following locatimni
hereby declare that we are
Beginning Ending
Address Location. of Date of Date of
Custorer's Name Garbage)Traan pimkaihd 'ortzai Contract
firellUMUONleitodisIChumh 61.4RandolanSteWAratedoo IA50702 01101/2022 1211M22
CONTRACT PERIOD MUST COVER AT LEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
Waterlmo, City Hail, 15 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 an 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
ci,4ring the current calendar year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.
3/9/2022
Date Signalle of Authorized Company RepresenEiT7We
110 Dunham PI, Waterloo, IA 50703
CmpanY's Address
10
Garbage & Trash Haulers Permit License
finsaed by lllack Hawk County)
PLEASE RETURN TO: CITY CLERK' 4 FINANCE OFFICE
713 MULBERRY STREET
WATERLOO, IOWA 514703
City Clerk's Copy - white Customer's Copy - yellow