Service Address:

City:

State:

Customer Name:

Zipcode:

Township:

Phone Number:

Email Address:

Account Number:

Water Line Maintenance Program

Sewer Line Maintenance Program

Interested In:

I acknowledge that I have read the Maintenance Program Terms & Conditions

The Property owner and or customer, when they forward the attached form online to the Authority,
acknowledges and agrees that they have read the full description of the Authority’s maintenance
program and agree to be bound by its terms and conditions, and furthermore, the property owner
and or customer by executing this form, hereby warrants and represents to the Authority that there
are no preexisting conditions in either the sewer lateral and water main that would warrant repair.
If the representation set forth here are to be determined to be invalid or a misrepresentation, the
Authority will not be obligated to meet its obligations as set forth in the Maintenance Program.
Lastly, by forwarding this form to the Authority, all owners of the property are deemed to have
consented to participation in the program and have read the terms and conditions of the Program.

BCWSA Maintenance Program Online Sign Up Form

Commercial

Residential

Association:

(optional)