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't.�,���!. � S � Water Department x`t'�1 r J
Address -S��"� � �T��/E 77� S�
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� Name�Q� Z Fl (l �.1 t
Date ��oZ � ���
ld Nleter Number � �
Old Meter Reading i S
Replacement No. 5 /
Replacement Reading Y`
Replacement Make c� �
ERT# ��� 1 � � l70
Replacement ERT#
Remarks: �'� �� ��S ���
Signed
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