Fillable TURN ON-OFF FORM-FAX-EMAIL 2015(1)

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TURN ON-OFF FORM-FAX-EMAIL 2015(1)

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Date _______________
DL# ________________
Home # _____________
Work # _____________
Meter Reading ____________________ Owner ____Yes____No
Office Use Only
I hereby request the water meter be (check one) ____ turned on ____ turned off ___ read only - office use only
at _________________________________________________________________ on ___________________________
SERVICE ADDRESS EFFECTIVE DATE
I understand only authorized City personnel can turn this meter on or off. Anyone turning meter on or off will be charged a $50.00
penalty. The City of La Grande is not liable for any damages occurring to my property by reason of water leaks or damaged pipes.
I agree a non-refundable connect fee will be billed on first billing. Checks returned for any reason will be assessed a $35.00 fee.
_______________________________________________ __________________________________________________
APPLICANTS NAME APPLICANTS SIGNATURE
____________________________________________________ PER PHONE REQUEST - (OFFS ONLY) ____________ office use only
MAILING ADDRESS
PHOTO ID REQUIRED
***********************************************************************************************************
WATER/SEWER SERVICE CITY OF LA GRANDE
REQUEST 1000 ADAMS AVE.
WWW.CITYOFLAGRANDE.ORG PO BOX 670
LA GRANDE, OR 97850
FAX - 541-962-1322 PH - 541-962-1313
Account # ____________
ID # __________________
MXU # ________________
OFFICE USE ONLY
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TURN ON-OFF FORM-FAX-EMAIL 2015(1)

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Completed 1 June 2021

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