| HANDY SANITARY DISTRICT | Water * Wastewater |
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3/28/05 |
Account Number: ____________________ |
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Hydrant Meter Rules and Responsibilities
By signing below, I waive any claim for damages that I may have against Handy Sanitary District. This is an Equal Opportunity facility. Federal law prohibits discrimination. To file a complaint of discrimination, write: USDA Director of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410. I have read this statement and agree with everything contained within it: |
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| ____________________________ | ____________________________ |
| Name (please print) | Company or Business Name |
| ____________________________ | ____________________________ |
| ____________________________ | ____________________________ |
| Mailing Address | Company Address |
| ____________________________ | ____________________________ |
| Drivers License Number | Phone Number |
| ____________________________ | ____________________________ |
| Social Security Number | Signature |
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P.O. Box 987 * Denton, North Carolina 27239 * Phone (336) 859-2553 * Fax (336) 859-3504 |
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