System Name: 

Contact Name: 

Mailing Address: 

City, State, Zip: 

Phone: 

E-Mail Address: 

No. of Customers or hookups: 

Type of System:  Water Only Sewer Only Refuse Only Water and Sewer Water and Refuse Sewer and Refuse Water, Sewer and Refuse

If Water, type of meters:  <Choose a meter> Invensys (Sensus) Neptune Other (please mention in comments)

Type of Billing:  <Choose the type of billing> Flat Rate - Coupon Usage Combination/Other

Questions/Comments:  

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