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M MEW <br />New LJ -Ron nA" <br />2401 Mounds View Boulevard,' Mounds View MN 55112-1499 <br />(763) 717-4000' Fax (763) 717-4019 <br />Inf(xS—mgun- vJP!A n,(y ww-mmoundmiewmn.otg <br />'Businesa Name- I ) -- <br />x <br />Ole A-)Onc& <br />Phone Number; <br />"M) <br />state- Fax Number, <br />'7 ,6--._ -533 -/1& <br />- --. <br />Email address: 6ilh-14_e'dg eto-b <br />e~ <br />DSA (Doing Business As): <br />Own era/Corporate Officers/Partners (name dqte,. <br />. ......... <br />a Fulf Name: <br />Addie iiT­-) <br />Roeldential (3 units or less) <br />I �Y-3A *7 <br />Garbage <br />Phone Number <br />Pax Number <br />ttlpta ng (four or mare units} <br />Yard Weate Annual L.'Gancia Fgw <br />StItutlonal $120 plus W <br />*�Oloamnle 21(11-10me Park Construction Debris <br />Pther_ <br />IMMM --- <br />Ywar <br />maleriater are to, be hauled, type of material disposed of at each location and the manner In which It Is to be disposed - <br />_,17 <br />VA <br />A carfiffeafi of Insurance wtffi Mounda View as Cho -60—rtfif&—fa Raider for tits haul 3 a burin mo and all vehlutea as must <br />provide as follows: (ay GarraralliablIftytri the 1b4bwh7Uazwwnft: BodIfy Injury, Pw accurmam or combined stngla ftk <br />$f'500AW-0; (b) POperfy damage, $000MW; (c) Auto flabAlifyin ffis Wtowing amounts., Property damage of combIlmd Whalia! <br />j2 --r onnolt-- P,�q-0,—W00, P&r-ccc!gWtx',u 000, ,00. <br />L i <br />, 000 ---i <br />I hereby 6ortify that Information provided on this application Is true and I understand that any mlareprasantationi�ida herein may be <br />grounds for denial of this application. I have been providedwith and tavlowed a copy of Chapter W3 of the Mounds �Avw Municipal Code <br />entiffed. 'Garbage and Re5yelln ':" and fUlly undep4aro re fromento outlined ihqreln, <br />_q <br />Applicant Signature, <br />copy 07 mWay L;ourlty Rvanal tit wad munwpal waste CAlacifoll arKI TmMporis(fon License RequIM to be aubffdffod with this appilcadon. <br />Business Llootm AWIaatlon License COUNCIL Approve! Data, <br />paymant $---- -- chadvCasw= Murnbar-- <br />CurraMwM MonthfyH9u6-z Report? You/No <br />