H03 Review Charges

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H03 Review Charges

Request for a review of assessed or unmeasured charges



Items marked * must be filled in.

1. Retailer details


2. Supply Point details

Please note one Form H/03 should be completed for each Supply Point.

Address of Supply Point

Reason for submission of this form. Please indicate below

Request by Retailer

Change of Retailer

Change of activity or tenancy

Assessment following a period of vacancy

Review of Unmeasured Charges

Resubmission of form

Challenge of assessment proposal made by the Wholesaler


3. Domestic water use at supply point


3.1 Employees

Please specify how many people are working at the premises to which the Supply Point relates


3.2 Water Use

Please specify which of the following domestic water facilities are used at the premises to which the Supply Point relates

Toilets and Wash Hand Basins

Staff Showers

Staff Canteen


4. Other water use and other information

Other water use includes any use not detailed above in 3.2.


Is the water used for any use other than canteen or employee toilet or shower facilities?

Yes

No

(please attach details in support of your calculations)

Other information to support the application.

Is there a Trade Effluent Consent associated with the premises to which this Supply Point relates?

Yes

No


5. Consent to contact the Non-Household Customer

The Wholesaler may wish to contact the Non-Household Customer to arrange a visit to the premises. Please indicate whether you give consent for the Wholesaler to contact the Non-Household Customer directly to arrange a visit to the premises.

YesPlease provide contact details below

No

Customer Contact Details

Please indicate if you want to be notified of the date of the visit

Yes

No

6. Declaration

I hereby acknowledge and declare that the information provided in this form is correct and up to date at the date of submission

"