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WATER GQMM
ST.,LU COUN3`Y ITIES P.O.BOX 77,$ FT.PIERC 2 s
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777
SEWER” RES
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SECURITYIEP : SE_ RVICE ADDRESS
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SERVICE FEE
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UBDIVISIt31Y LOT HI;OCK. G/
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This applica#ion he reby►request'agd pith+razes the Utility to ce dar avatar-and/
or iiii c d�spc t
GUAR:REV u
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•` services tb.tte,premises'desarbed aliova ut:accorclance with tha Ufuluties prea�cnt`or futum rates
LA'T'ERAL rules and regulations,which by reference are made a part,of this eontract,�Ap icaht"agrecs•to
the Utility promptly for such services in accordance with the established rules and regulations �}
TOTAL. CUSTOMERS DEPOSITS ARE NON NEGQTIAHLE ORTRANSFER AHLE. 3
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CUSTOMER �SOCIAL SECJ'
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NAME,OF EES Cu ;
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OFRIC US ONLY
DATE RECEIVE �':.
CASH' CHK# RECEIVED BY i
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