MOON TOWNSHIP MUNICIPAL AUTHORITY APPLICATION FOR SERVICE Fax: 412-262-9482

I HEREBY MAKE APPLICATION FOR USE OF SERVICES INDICATED BELOW AND AGREE TO BE GOVERNED BY THE RATES, RULES AND REGULATIONS AS ADOPTED BY THE AUTHORITY AND FURTHER AGREE THAT I SHALL NOT PERMIT SURFACE OR ROOF DRAINAGE TO BE CONNECTED TO, OR ENTER THE SANITARY SEWER SYSTEM FROM THE DESCRIBED PREMISES. SIGNATURE _____________________________________________________________________________

INSURANCE COVERAGE FOR SANITARY SEWER BACKUPS Following the unpleasant event of a sanitary sewer system backup, some sanitary sewer customers have learned that neither their insurance company nor the Moon Township Municipal Authority (MTMA) is responsible for damages incurred. The Moon Township Municipal Authority is not responsible for sudden and/or unforseeable sanitary sewer backups and many homeowners' insurance policies to do not provide coverage for these occurrences. Please check your property insurance to verify that you have adequate coverage. In the event of a sanitary sewer backup, you may call the MTMA to verify the sanitary sewer main is not clogged. If the backup is being caused by your sanitary sewer service line, it will be your responsibility to correct.            ________________ Customer Initial

MTMA use only:

Services applied for: ____Water    ____Sewer   Activation Fee: _________________________________ Date Paid: __________________________

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