Office of Utilities
215 S. Broadway, Louisburg, KS 66053
913-837-5371 ·
Fire Hydrant Meter Usage Agreement
Date: _____________ Projected Date to Return: _____________
Billing Information:
Company Name: ____________________________________________________________________________________
Company Address: ___________________________________________________________________________________
Contact Person ______________________________________________________________________________________
Company Phone: ___________________________________ Fax: _____________________________________________
Equipment Issued:
Hydrant Meter Meter #: ___________
Hydrant Wrench Yes ___________ No ___________
Hydrant Hose: Size: ___________ Length: ___________
Beginning Reading: ___________
Ending Reading: ___________
Total Water Usage: ___________
Deposit of $150 paid by: Check: _____________ Cash: _____________ Credit Card: _____________
____________________________________________ ____________________________________________
Contractor’s Signature Contractor’s Printed Name
____________________________________________ ____________________________________________
City Employee’s Signature City Employee’s Printed Name
Deposit will be refunded upon return of equipment less damage and/or loss of equipment.
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