HomeMy Public PortalAboutReduction 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:___________