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Application for Temporary Water Service

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Please correct the field(s) marked in red below:

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Requested Use:
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2
Name:
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Phone:
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Email:
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Address:
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Address:
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For Connection To:
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For Connection To:
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Water Demand Information:
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Water Demand Information:
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General Notes:
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General Notes:
For recycled water use, Applicant agrees that they have received the City of American Canyon Recycled Water Program User Guidelines and the California Health Laws Related to Recycled Water “The Purple Book”, and take the responsibility for disseminating pertinent information to Contractors.
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Applicant Signature:
 *
Applicant Signature:
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