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2. 
3. Town of Black Mountain Water Department
   160 Midland Avenue
   Black Mountain, NC 28711
   Phone: 828-419-9300
   Fax: 828-669-4204
5. First Name*
6. Last Name*
8. Service Address*
10. City*
11. State*
12. Zip Code*
14. Cutoff Date*
    Cutoff Date
16. Forwarding Address *
18. City*
19. State*
20. Zip Code*
22. Print Name*
23. Signature*
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