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WSW a an On <br />C 'it of' Roseville <br />0, <br />Finance Department, License Division, <br />2660 Civic Center Drive,, Roseville,, MN 5511,3 <br />(6511), 792-7036 <br />3 M <br />IS 4 <br />wEMMMI I <br />qW M <br />Fee Due*- $125.00, Year.:67.117 il . (License will be for January I to December 31. <br />Business Name LAI r- a PNIft 70�,aLxs rc- <br />Business Address �3 ) k to AA� -i�- roL w. Ilk, A <br />�Busineiss �Phon,e 6-)"—1 <br />z <br />7 <br />Contact Person ErnallAddress <br />MW <br />E,m,ergency Contac�t Information, _ G1, TI 12CL-C IIIII>7/ ga, -7- <br />If commpleted license should be mailed somewhere other than the business adldlr,ess, please attach separate sheet. <br />Recycling services, will be provided to (check ail that apply),- t-I efo <br />Residential Commerc,ia,l Multifamily ItRuft4isf <br />Nu�mber, of vehicles, the applicant proposes to, use in the collection of r,ecy,clables <br />Name and address of companies or materials, recovery facility where recyclables, will be delivered: <br />SM <br />r <br />Corrugated' Cardboard* <br />UrA <br />Other(Please -splecif <br />e�- <br />* Re�quired items for residential and multifamily haulers <br />I have been Provided with a copy of the City of Roseville Curbside Recycling Ordinance and understand that violation of any cif the <br />provisions, included in the oird,inanc,e may result in suspension or revocation ofthe license. <br />I have attached a certificate of liability insurance, a certificate indicating Worker Compensation coverage, and the fee of'$ 125.00. <br />Date Apoicant's S4nature Title <br />