City of Goodyear Construction Water Meter Request Form

1

Project Name (if applicable) 

Project Name (if applicable)

2

Major Cross Roads of Requested Location

 *

Major Cross Roads of Requested Location

3

Requested Service Start Date

 *

Requested Service Start Date

4

End Date of Use

 *

End Date of Use

5

Meter Usage: Estimated Daily Usage in Gallons

 *

Meter Usage: Estimated Daily Usage in Gallons

6

Meter Information

 *

Meter Information

Meter Purpose

City Inspector

7

Meter Size

 *

Meter Size

3" Hydrant Meter

4" F&D (Flushing & Disinfection)

6" F&D (Flushing & Disinfection)

8

Name (Employer Identification Number or Social Security Number Required at time of payment - do not enter EIN or SSN numbers on this form)

 *

Name (Employer Identification Number or Social Security Number Required at time of payment - do not enter EIN or SSN numbers on this form)

Contractor Name

Business Name (if different)

9

Primary Contact

 *

Primary Contact

First & Last Name

Primary Phone Number ext.

Business Phone Numberext.

10

Email Address (primary method of contact)

 *

Email Address

11

Billing Address

 *

Billing Address

Street

City

State

Zip

12

Under penalties of perjury, I declare that to the best of my knowledge and belief, the information stated above is true, accurate and complete.  It is agreed that by checking below the contractor will continue to be responsible for any damage to or theft of the Meter and billed for minimum charges and water usage, until the Meter has been removed by the City of Goodyear.

 *

Contractor, I agree

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