HomeMy WebLinkAbout814 W 4TH STExemption year:
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERLOO, IOWA
Date
Applicant's Name:
Billing Address:
Address of Exemption:
3 / 9 519`f erny
Telephone No. /
3-7 0 Z 1 fir W4 -1440 t9- s
Water Works Account No ! ' / 0 (e ^(p SJ /
Du..1"14(, Gk Qom' 8141 �'1 `� S 7a 4,115 at -
I request an exemption from Garbage Fees during the current'Calendar Year. 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.
Applicant's Signature
TO BE COMPLETED BY LICENSED GARBAG AND TRASH HAULER:
(A 1
Name
(We)
i&(JL �L
Compan
hereby declare that we are
a licensed trash hauler in the City of Waterloo, Iowa,
garbage and refuse at the following location:
Customer's Name
Address Location of
Garbage/Trash Pick -Up
CONTRACT PERIOD MUST
and that
Beginning
Date of
Contract
'It
1i L
we pick up
Ending
Date of
Contract
I131/2z
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. 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
during
Office
Dat C)•O cJ
event that the above person discontinues service with said company
the current calendar year, we hereby agree to notify the Clerk's
of this event by calling 291-4323.
77
Signatur
f Authorized Company Representative
7),
Comany's Address
411
Garbage & Trash Hauler's Permit License
(issued by Black Hawk County)
PLEASE RETURN TO: CITY CLERK & FINANCE OFFICE
715 MULBERRY STREET
WATERLOO, IOWA 50703
City Clerk's Copy - white Customer's Copy - yellow