NEW SERVICE REQUEST FORM Return both pages by FAX: 214-509-4567 or MAIL: City of Allen Utility Billing, 305 Century Parkway, Allen, TX 75013 12-1-2010 Date: ____________________________________ Residential ________________ 12-1-2010 Service Date: _____________________________ X Commercial _______________ Maketech Systems, Inc Name: ___________________________________ Spouse: ______________________________________ 103 W Main St Service Address: ______________________________________________________________________________________ 103 W Main St Mailing Address: ______________________________________________________________________________________ Allen City: _____________________________________ TX State: _____ 75013 Zip: __________________ 214-529-8826 Home Telephone: ___________________________ 972-359-0655 Business Telephone: ____________________________________ 08/30/1970 Date of Birth: _______________________________ 09062163 Drivers License No. _____________________________________ 76-8688696 Social Security No. __________________________ Maketech Systems, Inc Employer Name: _______________________________________ The Texas Utility Code allows the City to require the above information to obtain utility service. The City will verify the accuracy of the above information provided by the customer. The use of false information in this application shall be grounds for denial, suspension and/or termination of utility service. We report all of our customer’s payment history to a Credit Reporting Agency. Improper use of identifying information to obtain this service is a felony offense, in violation of Texas Penal Code 32.51, “Fraudulent use or possession of identifying information.” Identifying information consists of name, social security number, date of birth, and/or government-issued identification number. Please be advised that local area businesses and newcomer services desire to provide new residents information about their services and products. Texas Utility Code allows the customer to keep some or all personal information confidential. The information released consists of name, address and date of service only. The City does not charge to keep this information confidential. Please initial the appropriate line below your choice concerning personal information release. _______________ I agree that only my name and address be provided to local and area businesses. X _______________ I request that all of my personal information be kept confidential. The City of Allen requires all residents to pay a $50.00 water deposit for new service. This water deposit will be returned when service is discontinued. The City will deduct from the deposit any payments due for service. Please be advised that each residence is furnished with one (1) trash and one (1) recycle cart, which are provided by the City’s contracted solid waste collector. You are financially responsible for safeguarding the waste service provider’s trash and recycle carts from theft or unreasonable damage. Please confirm that such items are present at the residence when you initiate service. You should contact this office immediately if such items are not present at the residence. When you move, please assure the carts are turned over to the next occupant or owner so you are not charged for the containers after you depart. It is the customer’s responsibility to verify you are billed for the correct number of trash and recycle carts on your monthly utility bill. The city charges an additional fee for each extra trash cart (grey) and recycle cart (blue) above one of each. 0 0 Please complete the number of polycarts present at address: _____ Trash (grey) _____ Recycle (blue) Signature ________________________________________________ Page 1 of 2 The City of Allen is responsible for protecting the drinking water supply from contamination or pollution, which could result from improper plumbing practices. The purpose of this service agreement is to notify each customer of the plumbing restrictions, which are in place to provide this protection. Each customer must sign this agreement before the City of Allen will begin service. In addition, when services to an existing connection has been suspended or terminated, the water system will not re-establish service unless we have a signed copy of this agreement. PLUMBING RESTRICTIONS The following unacceptable plumbing practices are prohibited by state regulations. No direct connection between the public drinking water supply and a potential source of contamination is permitted. Potential sources of contamination shall be isolated from the public water system by an air gap or an appropriate back flow prevention device. No cross connection between the public drinking water supply and a private water system is permitted. No connection that allows water to be returned to the public drinking water supply is permitted. No pipe or pipe fitting that contains more than 8.0 percent lead may be used for the installation or repair of plumbing at any connection that provides water for human use. No solder or flux, which contains more than 0.2 percent lead, can be used for the installation or repair of plumbing at any connection which provides water for human use. SERVICE AGREEMENT The following are the terms of the service agreement between the City of Allen and the Customer. The City of Allen will maintain a copy of this agreement as long as the customer and/or the premises are connected to the water system. The customer shall allow his property to be inspected for possible cross-connection and other unacceptable plumbing practices. These inspections shall be conducted by the City of Allen or its designated agent prior to initiating new water service; when there is a reason to believe that cross connections or other unacceptable plumbing practices exist; or after any major changes to the private plumbing facilities. The inspections shall be conducted during the City of Allen’s normal business hours. The City of Allen shall notify the customer in writing of any cross connection or other unacceptable plumbing practice, which has been identified during the initial inspection or the periodic re-inspection. The customer shall immediately correct any unacceptable plumbing practice on his/her premises. The customer shall at his/her expense, properly install, test, and maintain any backflow prevention device required by the City of Allen. Copies of all testing and maintenance records shall be provided to the City of Allen. ENFORCEMENT If the customer fails to comply with the terms of the service agreement, the City of Allen shall, at its option, terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the customer. CUSTOMER SIGNATURE:_______________________________________ DATE:___________________ Return both pages by FAX: 214-509-4567 or MAIL: City of Allen Utility Billing, 305 Century Parkway, Allen, TX 75013 Page 2 of 2