HomeMy WebLinkAbout190 w 15th StExemption year: � L
PRIVATE HAULER GARBAGE EXEMPTION APPLICATION
RESIDENTIAL CUSTOMERS ONLY
CITY OF WATERL00, IOWA
Date woo-
Applicant's Name: ()c:� /�/ Telephone No, IA-
`�7Billing Address: C 9° 'At/jam�(� �/Uvj
Address of Exemption: t i 0 VV ' / SI, j, c �y/r/ /
(WaterworJcsAccoUnt No .: ! /' C9 a G� —� S- R c.7 4/"/I
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 qu lify for the exemption.
Alicant's Signature
TO BE C0MPLE EtBH
W
D BY L CENSED GA-X1GE AND TRASH HAULER:
(We) Blo �1mtin iras'
Company Name
hereby declare 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:
r'
Address Location of
Garbage Trash Pick -pp
I I ° r t6C..w r5414' S
Ending
Date of
Beginning
Date of
C. r- t
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. 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.
i t l t alas 3oritu
Date Signare of Authorized Com
pany Representative
Pi/ DerrC Y;-. Wt k(1w JR
Company's Address 506
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