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Reduction Factor FormAPPLICATION FOR REDUCTION OF SEWER CHARGES FOR NON-SEWERED WATER I.GENERAL INFORMATION COMPANY NAME _______________________________________________________________________________________ PREMISE ADDRESS ______________________________________________________________________________________ CITY__________________________________________________________________ Zip_______________ MAILING ADDRESS _______________________________________________________________________________________ CITY __________________________________________________________________ Zip_______________ CONTACT PERSON (PRINT) ___________________________________________ Title_______________________________ PHONE _______________________ FAX____________________ EMAIL______________________________ II.Account Information A.List all water and sewer accounts serving your facility, with the corresponding premise address. Please circle the account(s) for which reductions are being requested. Attach additional sheet(s) if necessary. SEWER ACCOUNT NUMBER WATER ACCOUNT NUMBER PREMISE ADDRESS (INCLUDING ZIP CODE) 1 2 3 B.List all non-sewered water usages at your facility for which you are seeking reductions in sewer charges: ________________________________________________________________________________________________ C.List any sources of water supply for this facility other than metered water agency supply (e.g. well water, hauled water, etc.): ________________________________________________________________________________________________ D.In order to process this application, information concerning the facility is required. Please attach a plot plan or sketch showing: 1.The water meter(s) feeding the facility labeled with the water and the associated sewer account numbers. 2.Water agency meter number(s) for each water account. 3.The locations of non-sewered water usages for which reduction in charges are requested. 4.The locations of any water supplies listed in Item C. above. III.Certification and Signature I have personally examined and am familiar with the information submitted in this document and attachment and certify the information to be true, accurate and complete. I further agree to operate under the provisions of all pertinent District ordinances and realize failure to do so may result in enforcement action being taken against me. Print Name ____________________________________________ Title_________________________________________________ Signature______________________________________________________________ Date________________________________ EMAIL TO: or RETURN TO: Metropolitan St. Louis Sewer District Environmental Compliance (for Finance) 10 East Grand Avenue St. Louis, MO 63147 FOR MSD USE ONLY: Date application received by Finance:______________ Date application received by DEC:_________________ Date of first customer contact by DEC:___________