TOWN OF BARGERSVILLE PO Box 420 – Bargersville, IN 46106 Phone: (317) 422-5115 – Fax (317) 422-5117 www.townofbargersville.org - support@townofbargersville.org POWER & LIGHT – WATER WORKS - SANITATION DEPARTMENT – STORM WATER APPLICATION FOR COMMERCIAL – NON RESIDENTIAL SERVICE Please print or type the following information: Application Date: ______________________ Service Connection Date: _______________ CUSTOMER INFORMATION NOTICE A deposit will be required for Utility service to be established The deposit will be applied to the final bill at time of service termination Business/Owner Service Application Name of Business/Owner: _______________________ Tax ID/SSN#: _________________________________ Tax Exemption: Yes No Indiana Form ST109 (Required) Address: _____________________________________ City: ________________________________________ State: ____________ ZIP: _______________ Email: _______________________________________ Business Phone: (____) __________________ Business Fax: (____) __________________ Primary Contact Name: ________________________ Primary Contact Phone: (____) __________________ Co-Owner Name: ______________________________ Co-Owner SSN#: ______________________________ Mailing Address, if different Address: ____________________________________ City: ________________________________________ State: ____________ ZIP: _______________ Address of Business Property Receiving Utility Service Address: _____________________________________ City: _________________________________________ State: ______________ ZIP: ______________ Property Contact Name: _________________________ Property Contact Phone: (____) _______________ Please select appropriate Business/Owner Type ___ Tenant (Please provide a copy of lease/rental agreement) ___ Landlord (Complete a Rental Property Owner Agreement) Business Type _____ Retail _____ Wholesale _____ Manufacturing _____ Church _____ Service _____ Distribution _____ Office _____ Other Planned Changes _____ Structure _____ Plumbing _____ Floor Drains _____ Electrical _____ Upgrade Elect _____ HVAC _____ Other Business Property Use(s) ___ Alcohol Sales/Beverages ___ Bale/Loose Combustible Fiber ___ Cellulose Nitrate Film ___ Compressed Gas ___ Dry Cleaning (Flammable Solvents) ___ Dust Producing Processes ___ Explosives/Ammunition/Fireworks ___ Flammable/Combustible Liquids ___ Food/Beverage/Food Products ___ Liquid Propane Gas ___ Other Hazards ___ Poisonous/Hazardous Chemicals ___ Recycling Waste ___ Smoking ___ Vehicle Repair/Garage ___ Welding/Cutting ___ Woodworking ___ X-Ray Developments Landlord/Mortgage Company Name: ________________________________________ Address: _____________________________________ City: _________________________________________ State: ______________ ZIP: ______________ Phone: (____) __________ By signing below I verify the information is correct to the best of my knowledge and agree that if I am a customer with Greenwood Sanitation, this application and/or information contained herein may be shared with the City of Greenwood. _____________________________________________ Owner/Company Representative Date _____________________________________________ Co-Owner/Company Representative --------------------------------OFFICE USE ONLY------------------------------ Meter Deposit: WTR ______ IRR ______ ELE ________ Amount: _____________ Receipt # ________________ Processed by: _____________________ Date: _______ Service Order # ________________________________ Date Account # _______________________________ Subdivision _______________________________ Lot # ______________