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)
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 )
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: