Swimming Pool Fill Form

(REQUEST FOR WASTEWATER CHARGE CREDIT FOR FILLING A POOL)

DATE:  _________________________

ACCOUNT #:  __________________________

NAME:  ___________________________________________               

ADDRESS:  ________________________________________

POOL INFORMATION:

DIMESIONS OF POOL:

          LENGTH X WIDTH OR DIAMETER:  ____________________________

          DEPTH OF POOL:  ____________________________________________

I agree to the terms that are set forth in the Filling of Swimming Pools Procedure paper.

Failure to return a meter supplied by the Village, within seven (7) days of being furnished one for purposes of determining the amount of the water actually used to fill a swimming pool; shall be considered just cause for termination of water service at the address given on the Swimming Pool Fill form, until such time as the meter is returned in good condition to the Village.

________________________________________                ______________________________

Signature                                                                                Date

Date meter was taken out:  ____________________________

Meter Serial Number:  _______________________________

Meter Reading In:   _________________________________

Meter Reading Out:  ________________________________

Total Wastewater Credit:  ___________________________

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