LEAK OR REPAIR REQUEST

HERMOSA WATER USER ASSOCIATION

PO BOX 41
HERMOSA, SD 57744

Please print form, fill out and send your request to the above mailing address or
bring to the next meeting.

Date: ___________________________
Name: __________________________________

Location :__________________________________________________________
___________________________________________________________________
___________________________________________________________________

Repair/Leak problem _________________________________________________

___________________________________________________________________

Received by: _________________________

Date: _______________________________