175-26 Attachment.pdf

TOWNSHIP OF WEST ORANGE 66 MAIN STREET, WEST ORANGE, NJ, 07052 ADMINISTRATION AND FINANCE Tel: (973) 325-4070 SUSAN McCARTNEY Mayor Fax: (973) 736-9182 E-mail: jditinvak@westorange ore JOHN C, DITINVAK, C.MJLO. rw. westorange.org Chief Financial Officer APPLICATION FOR REIMBURSEMENT FOR GARBAGE AND REFUSE COLLECTION COSTS PURSUANTTO CHAPTER 14 OF THE REVISED GENERAL ORDINANCES OF THE TOWNSHIP OF WEST ORANGE (PLEASETYPE OR PRINT) 4. wanes a? el Main St, bee ateveptone wumpEr: 173 356° O893 3, stReeT ADDRESS: SCD 30! dain sk WOmage, 23 O705c- 4, proce L. tT: Le |.(FOR WHICH REIMBURSEMENTIS Suen) 5. 6 NAME OF ASSOCIATION OR GROUP: B22 “Bole Main SK LOe aporess: £0. BOX AVS? Bron tign. WY W247. no. oF units 271 . 2, NAME OF FIRM PROVIDING SERVICE: A Shs at Apes: 9, PRESENT REFUSE COLLECTION COSTS: SAM Zi cal (WEEKLY, vrowmnkeonn> to, SERVICE PAYMENTS MADE BY (J INDIVIDUAL {) ASSOCIATION {OTHER [SPECIFY] —Maraspauaat-C 44, TOTAL AMOUNT OF REIMBURSEMENT SOUGHT: 20.7 42, PERIOD FOR WHICH REIBMURSEMENT 1S SOUGHT: Tan apt Dee Bory 49, ENCLOSE COPIES OF ALL BILLS FOR $WHICH REIMBURSEMENT IS SOUGHT. PLEASE SHOW NUMBER OF UNITS BEING COLLECTED FOR EACH PERIOD tA, COPY OF SERVICE AGREEMENT OR CONTACT, APPLICANT'S CERTIFICATION {certify that the foragairig statements and Information are true to the best of my knowledge ard pellef. | am aware that jen b) the foregoing ts willfully false, 1am subjact te punishment ais te TITLE Al p oar: 25-26 PLEASE RETURN APPLICATION AND COPIES OF BILLS TO: JOHN C. DITINYAK CHIRE FINANCIAL OFFICER TOWNSHIP OF WEST ORANGE 66 MAIN STREET WEST ORANGE, WJ 07052 : oo Oe AL USE : APPROVAL: Chief Flnanctal Officer ran =