This form is for online submission of termination of utility services application.
If you have any questions about this process, please contact the Finance Department at (209) 827-7000.
Today's Date * Date format: month/day/year (ex. 01/31/2016)
Name* (First and Last)
House Number* (enter a numerical value here)
Street Name* Be sure to include the correct ending (Ct., Way, Ln.). For streets beginning with a direction (e.g. W. J Street) be sure to include the street direction “N, S, E, W."
Unit Number (if applicable)
Mailing Address (if applicable)
Date to be disconnected * (Monday - Thursday before 12pm, the City provides same day service if notified prior to 12pm. Date must be in future, termination of service cannot be backdated.) Date format: month/day/year (ex. 01/31/2016) Disconnect Date *
Email Address * This is for our use only to contact you with confirmation and/or questions if needed.
Phone Number * Area Code and Number, ex. (209) XXX-XXXX. Again, for your use only if we need to contact you.
DL# and SSN (For security purposes, please provide Requestor Driver License Number and Last four digits of the requestor's Social Security Number )
Notes (optional) Indicate any additional information you would like to provide
By selecting this box and submitting this form, you acknowledge that you are the account holder or an authorized agent:
For verification purposes, please type in the text you see below: