Establish Service Order

ESTABLISH SERVICE ORDER

Last Name ______First & Middle Names ______

(As it appears on your ID)

______Service Address ______

Mailing Address ______Account # ______ Misc. Info:

______Previous Util. Customer? ______When ______# of mo/yr______Owner ______Renter______# in Household ______

Type:

Phone______ Single Fmly. ______Multi Family______Commercial. ______

DOB/ # of Units ______Holding Tank ______Seasonal ______

License # ______SS # ______

(We must see your ID) Lift Station ______Out of Town ______Spit _____ Pub. Authority _____

Email ______ Other ______

********************** FEES ********************** ********** SCHEDULE OF RATES ****************

Establish Service (2101) ______Water Customer Charge: $19. Per meter / Per month

Multi. Units $5. Per. unit /Per. month

Deposit (2103)______Water per gallon: $0.0109 per gallon, ($10.90/1000gal)

Other ______

Sewer Customer Charge: N/C for single unit service

Tax (2104)______Multi. Units $5. Per. unit /Per. Month

Sewer per gallon: $0.0157per gall. ($15.70/ 1000gal)

TOTAL FEES ______ Sewer W/Lift Station:$0.0232 per gall. ($23.20/ 1000gal)

DATE FEES PAID ______

DEPOSIT: The deposit will be according to meter size and description. The deposit will be refunded, plus interest within forty-fivedays after the date of disconnection, provided that the deposit and interest shall first be applied to any outstanding balance. Oncontinuing accounts with one year of timely payments, deposit will be refunded, plus interest.

CHARGES: All charges will commence on the date the service is turned on. All monthly charges will continue to be billed to thecustomer who has signed the connect order until a disconnect order is requested. Monthly sewer billings will not be discontinuedunless the water service is disconnected. Each reconnect will be charged at the regular fee as listed in the schedule of rates. Monthlyservice charges are based on the monthly water usage and billed at the end of the month.

AUTHORIZED BY: ______DATE: ______

Signature (Customer responsible for the monthly billings)

Printed Name: ______

City of Homer 491 E. Pioneers Ave., Homer AK 99603 Ph: 235-8121 Ext. 0 /Fax: 235-3140

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For use of meter tech:

_____ Establish Service / Connect Water _____ Meter Read Only

_____Contact Customer to schedule appt. _____ Start w/ last Read

Effective Date ______Service Address______

Phone Number ______Parcel Number ______

Relay Number ______Route ______Service ______Size of Meter______

Meter Reading: ______E-Mailed:______@______Posted to:______