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2. 
3. Coachella Valley Water District
   Canal Water Service Request - Authorization of Agent (CVWD106)
   
   
   
   
   
   
5. Meter Number (1 meter per application)*
7. Company Name*
9. Property Owner First Name*
10. Property Owner Last Name*
12. Property Owner Title*
13. Property Owner Email Address*
15. Property Owner Telephone Number*
16. Property Owner Telephone Number Type*

    1. Cell phone
    2. Work
    3. Home
18. Property Owner Mailing Address *
20. City*
21. State or Province*
22. Zip or Postal Code*
24. Is the billing information the same as above?*

    1. Yes
    2. No
26. Billing Company Name
28. Billing First Name
29. Billing Last Name
31. Billing Title
32. Billing Email Address
34. Billing Telephone Number
35. Billing Telephone Number Type

    1. Cell phone
    2. Work
    3. Home
37. Billing Mailing Address
39. City
40. State or Province
41. Zip or Postal Code
43. Are you the new owner of the property?*

    1. Yes
    2. No
44. Will existing users stay on the account?*

    1. Yes
    2. No
46. List user names to remove from the account.
48. Will you be leasing the property?*

    1. Yes
    2. No
49. To whom will you be leasing the property?
51. Is a well located on your property?*

    1. Yes
    2. No
52. State Well Number
53. Active?

    1. Yes
    2. No
54. Abandoned?

    1. Yes
    2. No
56. Will you be multicropping?*

    1. Yes
    2. No
58. Water will be used for: (check all that apply)*

    1. Bell Peppers
    2. Carrots
    3. Citrus
    4. Dates

    1. Grapes
    2. Nursery - Trees
    3. Okra
    4. Oriental Vegetables

    1. Strawberries
    2. Construction
    3. Duck Farm

    1. Fish Farm
    2. Golf Courses / Lakes
    3. Industrial Hemp
60. Industrial Hemp Certification*

    I hereby certify that I will comply with all federal, state and local requirements as it pertains to the production of industrial hemp, including any federal requirements of the United States Bureau of Reclamation, which owns a portion of the facilities used to provide agricultural water service. CVWD makes no representation or warranty regarding what, if any, federal, state or local requirements may apply to hemp production. Water service may be subject to interruption or termination if CVWD determines, in its reasonable discretion, that USBR, the California Department of Food and Agriculture, or County Agricultural Commissioner has denied, revoked, or changed any of its authorizations, which result in a prohibition against Applicant’s hemp production. Further, it shall be the responsibility of the applicant to provide CVWD proof of valid registration with the County Agricultural Commissioner on an annual basis. Applicant hereby waives and releases CVWD from any and all liabilities, which may arise from Applicant’s use of water service for hemp production.

    1. I acknowledge and agree to comply with all District Regulations, Ordinances, Policies and Rules, or amendments thereto.
62. By typing or signing my name, I certify that I understand the terms and conditions outlined above and that to the best of my knowledge the information I provided is true and correct.*
64. Title*
65. Date*
    Date
67. Industrial Hemp Registrant Name*
69. Industrial Hemp Registration Number*
70. Industrial Hemp Registration Expiration Date*
    Industrial Hemp Registration Expiration Date
72. Attach Copy of Industrial Hemp Registration Here*
74. Parcel Information*

    This Canal Water Service Request – Authorization of Agent form must list the parcel and all additional parcels served by the above meter. This will allow for the proper application of paid Canal water charges to each parcel to which water is actually being delivered.
    
    CREDIT WILL NOT BE GIVEN TO PARCELS NOT LISTED ON THIS FORM OR TO PARCELS TO WHICH WATER IS NOT ACTUALLY DELIVERED.
    
    

    1. I hereby apply for water service and certify that water is served by the above meter to the following parcels:
76. Parcel Number*
77. Number of Acres*
78. Section*
80. Township (S)*
81. Range (E)*
82. 1. Check here to add another parcel
84. Parcel Number*
85. Number of Acres*
86. Section*
88. Township (S)*
89. Range (E)*
90. 1. Check here to add another parcel
92. Parcel Number*
93. Number of Acres*
94. Section*
96. Township (S)*
97. Range (E)*
98. 1. Check here to add another parcel
100. Parcel Number*
101. Number of Acres*
102. Section*
104. Township (S)*
105. Range (E)*
106. 1. Check here to add another parcel
108. Parcel Number*
109. Number of Acres*
110. Section*
112. Township (S)*
113. Range (E)*
115. List additional parcels on a separate page or upload here.
117. Water Orders*

     1. I authorize the following individuals to order water through this meter
119. Property Owner First Name*
120. Property Owner Last Name*
121. Property Owner Cell Phone*
123. 1. Check here to add another individual
125. First Name*
126. Last Name*
127. Cell Phone*
129. 1. Check here to add another individual
131. First Name*
132. Last Name*
133. Cell Phone*
135. 1. Check here to add another individual
137. First Name*
138. Last Name*
139. Cell Phone*
141. 1. Check here to add another individual
143. First Name*
144. Last Name*
145. Cell Phone*
147. 1. Click here to add another individual
149. First Name*
150. Last Name*
151. Cell Phone*
153. List additional individuals on a separate page or upload here.
155. Terms & Conditions*

     1. I understand that the start date for service depends on verification by CVWD that the water lines are in proper working order.

     I hereby authorize the above named water user, if any, and his/her designees to sign or give orders to Coachella Valley Water District for the delivery of water through this meter. By signing this document, I certify I am the legal property owner for the parcels identified within this application; all information is true and correct. I assume all responsibility for any bills, costs, loss, damage, penalties, charges, or fees associated with this meter under the Regulations of the District. This authorization shall be revocable at any time upon written notice to the District. A $46 Account Establishment Fee will appear on my first bill. I acknowledge and agree to comply with all District Regulations, Ordinances, Policies and Rules, and amendments thereto. Where the demand for water exceeds the available water supply, water orders may be delayed except under emergency conditions as determined by the District. Service may be interrupted for the purpose of repair and maintenance at any given time.

157. By typing or signing my name, I certify that I understand the terms and conditions outlined above and that to the best of my knowledge the information I provided is true and correct.*
159. Property Owner Title*
160. Date Signed:*
162. CVWD Use Only
164. New Meter Sequence
165. Additional User
166. Refund Agreement Number
168. Last Date Meter Used
169. Lateral Remarks
171. Notes
173. Processed By:
175. Customer Service
176. Date
178. Customer Billing
179. Date
181. Zanjeros
182. Date
184. Customer Billing
185. Date

187. COACHELLA VALLEY WATER DISTRICT
     Post Office Box 1058
     Coachella, California 92236
     (760) 391-9600
     (760) 398-3190 - fax
     CustomerService@cvwd.org

     rev 9/2022

Leave This Blank:


188. 1. Receive an email copy of this form.
189. Email address

     This field is not part of the form submission.

190. Submit

* indicates a required field