Sewer Appeal Form

City of Glendale		Utilities Billing Department
Sewer Fee Adjustment		Phone: 623-930-3190
5850 West Glendale Avenue, Ste 104		Fax: 623-930-2186
Glendale, Arizona 85301-2599		7:30am-5:00pm, Mon – Fri
Utilitybilling@glendaleaz.com

Date

Customer Name

First NameLast Name

Account Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The information provided below will be used to adjust the sewer fee for water usage that is not discharged to the City's wastewater collection system. The sewer fees are based on 90% of the average water consumption billed DURING THE MONTHS OF JANUARY, FEBRUARY, AND MARCH. During those months, the following was diverted from the sewage system:

1) Winter lawn (sq. ft.):

2) Garden (sq. ft.):

3) Total number of shrubs:

4) Total number of trees:

5) Swimming pool size (length x width)

6) Pool filled, pool repairs or leaks fixed during January - March:

YesNo

(NOTE: attach letter from pool company specifying gallons needed to fill pool and any receipts for repairs made)

Browse Files

7) Number of occupants:*

Comments:

The above information is accurate to the best of my knowledge. I understand that the given values are subject to verification and if there are errors, I will be charged for any incorrect allowance not previously billed. Any allowance based on the information provided will be reflected in future bills. Adjustments will be made for no more than three months prior to the date mailed. I understand that the appeal, if approved, is only valid up to 3-Years.

Your Name

Date

Questions should be directed to Billing Services at (623) 930-3190.

Return your completed form within 90 days of your May bill of the current year (including any attachments).

By [checking this button, providing my name & clicking ‘submit,’] I declare that the information I have provided is true, complete, and accurate, and that all the information I have provided is about me or another person who gave me permission to provide such information

SEWER APPEAL FORM