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NAME OF SPOUSE
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SECURITY DEP
SERVICE FEE
SAME DAY FEE
OVERTIME FEE
METER INSTALL.
CFC/WATER
FPUA CFC
CFC/SEWER
GUAR. REV.
LATERAL
NAME I VC1111'I /I = i.N//
SERVICE ADDRESS j`� i i`� 1 l'�, )y o / 4' r -f
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PHONE # �il./� - '� / i MOVE IN/CLOSING DATE
This application hereby request and authoriies the Utility to render water and/or sewage disposal
services to the premises described above in accordance with the Utilities present or future rates,
rules and regulations, which by reference are made a part of this contract. Applicant agrees to pay
the Utility promptly for such services in accordance with the established rules and regulations.
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
SOCIAL SEC/ (,�
FED ID /S! — 3u> o
SPOUSE SOCIAL
\� + OFFICE USE ONLY1 `7 IGy j
DATE RECEIVED CASH CHK # RECEIVED