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Potable Water Request Form
Potable Water Request Form
IMPORTANT:(To Be Completed by Licensed Vessel Agent) Potable water requests will not be processed until vessel is secured at dock.
Agent Information
Licensed Shipping Agency Name
Agency Representative
First
Last
Agent Phone Number
Agent Email Address
Date
MM slash DD slash YYYY
Vessel Information
Vessel Name
Dock Assignment (Select One)
Cargo Docks
Dock 1
Dock 2
Dock 8
Dock 9
Dock 14
Dock 15
Oil Docks
Dock 1
Dock 2
Dock 4
Dock 7
Dock 11
Bulk Terminal
Dock 1
Dock 2
Tariff Acknowledgment & Financial Responsibility
I acknowledge and accept full financial responsibility for all applicable potable water and connection charges associated with this request.
Per Tariff Item 3.402, the undersigned licensed shipping agent acknowledges and agrees to the following charges:
• $8.00 per 1,000 gallons of potable water delivered
• $25.00 connection fee per hookup at Terminal Facilities
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Intercoastal Waterways
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Liquid Bulk
