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CITY OF LITTLE CANADA <br />ORGANIZED COLLECTION EXEMPTION APPLICATION <br />515 Little Canada Road East, Little Canada, MN 55117 <br />(651) 766 -4029 Fax (651) 766 -4048 <br />Name: j n hi v to 4 \S a'\ e.Ar e <br />Address: R g W <br />Phone: ImSt- �1Ra- 9.91f� <br />I r <br />IC`n. v\ PVC'' C'CO\O. IN <br />Date: ._q_1 (0-oa' <br />Signature of Resident:. <br />TYPE OF EXEMPTION REQUESTED: (Check one) <br />\ I certify that the business I own and operate within the City of Little Canada has a dumpster that I am <br />paying for and using for my residential refuse. Therefore, I choose not to participate in the City of <br />Little Canada's organized refuse collection program. I realize that if I should no Longer own said <br />business, I am responsible for immediately notifying the City and organized collection would then <br />resume at my home address <br />L14,- 331•�sc0 <br />(Business Phone #) <br />(Name and Address of Business) <br />41-6 1710 R64(n <br />(Tax ID #) <br />(Name and Phone # of Hauler used at Business) <br />I certify that I am "working for a refuse hauler who provides me with free collection of my residential <br />refuse as a benefit. I realize that I am responsible for disposing of my refuse at my, place of <br />employment (unless employer is the hauler assigned by the City to the resident's collection area). I <br />have attached a written notice from my hauler stating that I have the benefit doming to me. I realize <br />that if I no longer work for said employer, I am responsible for immediately notifying the City and <br />organized collection would then resume at my home address. <br />(Name and Phone # of Employer) <br />For City of Little Canada's Use Only: <br />Approved <br />Disapproved (Explain) <br />By: Date: <br />5 <br />