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Request for Water & Sewer Adjustment Due to Leak

Account Name

Service Address

Mailing Address

Date Leak Discovered

Date Picker

Date Leak Repaired

Date Picker

Under penalty of law, I certify that the information above is true and correct.

I certify that the above described leak has been repaired by:

Upload Receipt(s) for Leak Repair

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I have read a copy of the Water & Sewer Adjustment Policy.