0756Sic CITY OF CLERMONT
UTILITY SERVICE REQUEST FORM
Date of Request: 0 1 , 20 C,`-t Date of Service:
Customer Name: L-oAvn iA BoA€Y'S, It C .
Phone Number: oak 1 7 - ?,T .75
Mailing Address: 15 . Ur) . 1-%lnco1C, Avt' _
City:C\-errnby State: -Ror A c._ Zip: M l k k
Service Address: `751 Wc-S- T/enue
City: C1.e y- - State: -F\ Zip: 'li.1`\\
Lot#: Phase:
Subdivision:
Owner Name: . ,N4- .L 6,\nC S )L .
Mailing Address: IUO hou-Eico. 0I-'to Dr.
City: CAe'cmoy * State: F Iv d c.Zip: a41 1 t
Forwarding Address: 14
City: State: Zip:
4 Check one: Commercial -./ Single Family Multi-Family and#of Units
Meter Tampering Fee — A fee of $50.00 per incident shall be charged to the
Individual responsible for payment of the utility account.
City staff completes this section
Utility Account Number:
Meter Location:
Meter Serial Number:
Last Meter Reading:
Employee:
Service Requested
Turn-On Re-Read
U 1.3-v--,Turn-Off Meter Install 1 I1
Notes: 0
Water Department
Meter Reading: Meter Serial #: Manuf.:
Date of Service: Comment:
Billing Department
New Account Added: Account Finalized:
New Account Fee: Deposit:
Notes:
City of Clermont 352) 394-4081
685 W. Montrose St.
P.O. Box 120219
Clermont, FL. 34712-0219
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