Owner/Tenant's First Name: *

Owner/Tenant's Last Name: *

Water Account Number: *

Please note that effective , Water Service at House # on (street), in (village), will be turned: OFF or ON

PLEASE NOTE THAT THE REQUESTED SERVICE (SHUT OFF OR TURN ON) MAY TAKE AN ADDITIONAL 3 BUSINESS DAYS FROM THE EFFECTIVE DATE ENTERED ABOVE

Please send bill to:     Owner      Tenant

Service Address: *

Mailing Address: *

COMMENTS:

Signature *

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