HomeMy WebLinkAbout701 & 703 RANDOLPH ST Kamp-�= o22— 2-o9 (
I APPLICATION
RESIDEWL'T L CUSTONERS ONLY
CITY OF MATERLOD, 100A
Date v2 2
Applicant's Bane: D ' /Ll'CX��yel ome �o_ !�3 !, r
Billing Address: �.�' �7,5- f -S 7` ��he s a' ZZ C ��` � �7
Address of Exemption: Q3l 7Q/ �lPi �j
Water Works Account No.: / 7a .--Sf���/9
I request an exemption froze. Garbage Fees during the curment Calendar year. I
employ the services of a licensed trash hauler_ Only the location where the
trash hauler picks up garage and trash w"ll qualify for the. ez ion,/
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Applicant's Signature
TO BE CUI(PLET,B/D BY LICENSED GARBAGE AND TRASH .
HAUIXR-
(We) 1 lWC`l 01;AWt hereby declare that we are
Company Namw
a licensed trash hauler in the City of Waterloo, Fora, 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-Oa Contract Contract
t v�2chcoc�(- - U15 wh S'� 12- -2 1 12-31-22-
CONTRAcr PERIOD MOST COVER AT IEAST CURRENT CALENDAR YEAR
We understand that the above information is used by the Clerk's Office in
Waterloo, City Rall, 715 Mulberry Street, to determine eligibility for
exertion 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 Baste Commission.
In the event that the above person discontinues se=41ce wrath sand company
during the current calendar year, we hereby agree to notify the Clerk's
Office of this event by calling 291-4323.
� � —22-Z 1 CW4',
Date Signature df Authorized Company Representative
80 Ddrborn du2
Company's Address
\ I
Gage S Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK S FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow