BORING WATER DISTRICT #24

BORING WATER DISTRICT #24

PO Box 66, Boring, OR 97009 (503) 663-4594

LEAK ADJUSTMENT REQUEST

 

NOTIFICATION DATE: ________________                                                                   RETURN FORM BY: ________________

ACCOUNT NUMBER: ________________

CUSTOMER NAME: _____________________________________

SERVICE ADDRESS: _____________________________________

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HOME PHONE: _________________ WORK PHONE: __________________

DATE LEAK DISCOVERED, __________________________________________________________

DESCRIPTION OF LEAK

AND REPAIR: __________________________________________________________ (ATTACH RECEIPTS)

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PLEASE NOTE:

Completion of this form does not guarantee an adjustment will be made to your water bill. All requests are evaluated based upon the attached Leak Adjustment Policy. In order to qualify for an adjustment, the leak must be repaired and copies of repair receipts along with this form must be returned to the office by the date noted at the top of this form. If the form is not received by that date you will be responsible for the entire amount of the water used.

CUSTOMER SIGNATURE: ______________________________ DATE: ________________________

DATE FORM RECEIVED IN OFFICE FROM CUSTOMER: ___________________(1/9/2007)