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* 1. Utility Name

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* 2. Person of Contact

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* 3. Street Address

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* 4. City

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* 5. State

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* 6. Zip

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* 7. Email

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* 8. Phone

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* 9. County

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* 10. Regulated By

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* 11. Number of Connections

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* 12. Water

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* 13. Wastewater

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* 14. Has your system been impacted by severe weather?

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* 15. If you were impacted by the 2022-2023 winter weather events please describe the nature of the impact.

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* 16. Have you received support from local, state, or federal agencies? If yes, please document what type of assistance you received and list which agency.

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* 17. Is there further assistance you would like to receive or information that we may be able to assist you with?

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* 18. Anything else you wish to add?

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