YOUR INFORMATIONName:* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: *(Home)(Work)(Cell)Email:* BOAT INFORMATION Boat Name:* Harbor:*Choose One31st Street59th StreetBelmontBurnhamDiverseyDuSableJackson InnerJackson OuterMonroeMontroseAssignment* Boat Length:* (Feet)Boat Type*Choose One...PowerSailNumber of Tanks*Choose One....OneTwoThreeEstimated Size of Tank(s)*GallonsNumber of Fittings* One Two Three Fitting 1 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftFitting 2 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftFitting 3 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftSERVICE REQUEST Requested Date* MM slash DD slash YYYY Actual date of service dependent on availability. Service available Monday thru Friday Only.Comments:PAYMENT INFORMATIONOn Call Service $50.00 per serviceMore than one pump-out fitting: $5.00 per fittingAdditional charge for greater than 50 gallons per tankMajor credit cards accepted with a $25.00 electronic transaction fee on charges greater than $1,000.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name By submitting this form, I hereby agree to abide, by the rules and regulations of the Chicago Park District governing the use of harbors, and also to abide by all ordinances of said Park District. I further agree that the Chicago Park District shall not be held liable for any loss or damage, by theft or otherwise, to my boat or property while using a harbor or occupying any stall and in consideration of the permit so issued to me I hereby release the Chicago Park District of any claim by me for aforesaid loss, damage, or theft. I authorize a representative of the Chicago Park District to board the above boat at all reasonable times for inspection to determine it's seaworthiness, safety, and compliance of all Park District rules and regulations including the prominent display of a proper decal and compliance with the anti-pollution regulations. Pumpout* Price: Additional Fitting Charge* Price: $0.00 Promotion Code Promotion Discount Price: $0.00 Today NumberServiceDateToday-MonthToday-DayService-MonthService-DayMonth-DifferenceDay-DiffernceDay-Difference-2Total $0.00 CAPTCHA