Request to Remove Riser/Gas Service Line
I, __________________________ declare that I am the owner of the property listed below:
I wish the gas service line to be removed at the above location. I understand that should I ever wish to have gas service again at this location, I will pay whatever the cost to install new service in full.
Property owner signature: ____________________________
Office Use: Service Order __________________ Picked up on: __________________
Please return completed form to: P O Box 470, Raceland LA 70394 or 985-537-5282 (Fax) or e-mail to email@example.com