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CITY 017 LA PORTE <br /> COMMERCIAL APPLICATION <br /> WATEWSEWER SERVICE NO. <br /> DATE TAKEN CUST REP DATE NEEDET) ACCT# <br /> CU$TaMER NAME_A)nn_p A'Y 3 LLL <br /> (LAST) ^` � � ��,,,�']'^ ' <br /> SERVICEADDRE4.S 43-3 D !� EO IAL _e# �.. <br /> MAILING ADDRESS 4+ 50 MEW UJESr b9_1 YC. <br /> PHONENUMBER - !l�- 2 `-2 l 9 DO YQU,,, RENT___LOWN <br /> TYPE OF BUSINESS II&F 24 HOUR EMERGENCY PRONE# <br /> OWNER/MGR NAMI3 NEIi/MORPHONE# <br /> FLAMMABLBS/COMMIlM! Now, <br /> o E , <br /> OW'NER INFORMATION y <br /> PMPI.QYED AT, n T� .L�)qT, <br /> DRIVERS LICPkM#+-� �0�{ 1 // ca nnnR�ss _� I,ta�d f �_ 1�lZ 1 V8 <br /> TAX ID 9 ( � ^.4 5 t4 `( CO PHONE# 2_21 - 4-7-4 - 70�D_ <br /> THE UNDERLSIGNQD HEREBY APPLIES FOR WATER SERVICE WITH THS CITY OF LA PORTS AND IS HEREBY <br /> SUBJECT TO THE POLICIES AND PROCEDURES USED BY THIS DEPARTMENT. BILIS MUST BE PAID WffMN]S <br /> DAYS ATTER MAILTNG OR A PENALTY WILL BE APPLIED. FAILURE TO RECEIVE YOUR BILL DOES NOT <br /> IVAIVE THE PENALTY, IN THE EVENT THAT THIS ACCOUNT IS TRIUMINATED AND LEFT WrM AN <br /> OUTSTANDING BALANCE,BY SIGNING BELOW;YOU AUTHORIZE THE CITY OF LA PORTE TO REPORT YOUR <br /> DELINQUENT ACCOUNT TO THE CREDIT BUREAU. «*" DEPOSITS ON COMMERCIAL ACCOUNTS ARE <br /> IIEFUNDED AF1I3K T13RMINX)ION OP SERVIC13 WITH Ttili CITY OF LA PORTS.**** <br /> BY INITIALING HERE, I HEREBY GIVE PERNUSSION MR MY ACCOUNT INFORMATION TO BE MADE PUBLIC. <br /> INITIALS _-- ----. IF NOT MLE CdUINTtdRMATION WILL REMAIN CONFIDENTIAL. <br /> Oj"R Si TORE <br /> ss�����s��������r���M•Fr�t�rr��i ■�����t�����a��rrrr■rra���������rrr■■■r■■■rRr■rr <br /> NEW SI3RVICE.0MOSITAMOUNT PAID RECEIPT NUMBER <br /> WUM-0mvECOPY GIt9FA-CUSTOMER COPY GOLD-blMDEPT NO. <br />