Application for Water from Water Filling Station

2. Company Name (if applicable)*
4. Site Address*
6. City*
7. State*
8. Zip Code*
10. Project or Permit Number *
11. Contractor License Number (if applicable)*
13. Have you utilized the Water Filling Station in Cotati before?*

    1. Yes
    2. No
17. Billing Contact Information

    This is the individual who is responsible for submitting the deposit and paying the monthly billing for consumption.

19. Contact Name - Billing Manager*
20. Billing Manager - Phone Number*
22. Billing Manager - Email Address*
24. Billing Address*
26. City*
27. State*
28. Zip Code*
32. Water Filling Station Manager

    This person is responsible for remaining compliant with the use of the water filling station at all times.  

34. Contact Name - Account Manager*
35. Phone Number*
37. Email Address*
39. Estimated Dates Required*
    Estimated Dates Required Start Date

    Estimated Dates Required Start Time

    —

    Estimated Dates Required End Date

    Estimated Dates Required End Time
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field