Bulk Water Request

Bulk Water Request Form

Provide your company and contact details, confirm the terms, and submit your request for bulk water service.
Company Information
Company Name
Contact Person's Name

First NameLast Name
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Filling Information
Fill Station: 23304 Tile Mill Road, Woodburn, IN 46797

*Please contact the superintendent to get permission for an alternate filling location, if needed. Ryan Walls, (260) 450-2410.

Contact a city staff member before you begin filling at the fill station.
Terms
REPORTING: It is the responsibility of the applicant to report water usage to City Hall every month by calling 260-632-5318 or emailing l.dolinski@cityofwoodburn.org. Failure to report water usage may result in the termination of the applicant's bulk water permissions.

PAYMENT: The applicant agrees to pay monthly (or a schedule agreed upon by City Hall and applicant) for the utility services rendered. The charges for service will be made at the regular established rate for gallons received. See Ordinance 25-1435 for rates per 1,000 gallons.
By signing below, you agree to the terms and confirm that all the information provided on this form is accurate. I understand that any false or misleading information shall be cause for the City to deny or cancel service and demand immediate payment for any amounts which are due.
I agree to the terms above.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Bulk Water Request Form

Company Information

Filling Information

Terms