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Survey/Form Review
SCMU Application - Inside City Multi-Residential

SANTA CRUZ MUNICIPAL UTILITIES (SCMU)

CITY MULTI-RESIDENTIAL ACCOUNTS

WATER, SEWER, REFUSE SERVICE SIGN-UP

1. SERVICE LOCATION INFORMATION

Service Address - Street, Apt/Ste:*

Service Address - City, State, Zip Code:*
Total number of persons who permanently reside at the above service address:*
(A permanent resident is someone who resides at the service location for at least 21 days within each monthly service period.)
I declare, under penalty of perjury, that the above information is true and correct. I understand that I am responsible for notifying the City of Santa Cruz Water Department within 10 days if the number of persons who permanently reside at the residence changes. I understand that false information will result in Excess Use Penalties for any water used over the standard allotment, and could result in discontinuation of water service and/or full prosecution as allowed under the laws of the State of California.
I have read, understand, and agree with the above declaration.*
Requested Service Start Date (No weekends or holidays):*

Requested Garbage Cart Size (The number of carts of the size requested will be determined based on the number of dwelling units):*
Requested Dumpster Size:*
Dumpster Pickup Frequency:
Dumpster placement on site? (Street placement is not allowed unless approved in advance by the Public Works Department)

What type of material will be in the dumpster?

The applicant agrees to comply with the Container Rental and Indemnification Agreement (Mandatory if requesting dumpster service): I hereby agree to indemnify, defend and hold the City of Santa Cruz, its agents and employees harmless from any claims for damage, death or personal injury which may result from the dumpster's use, movement or placement during the course of its rental through this account with the City of Santa Cruz. This agreement does not extend to liability arising from the negligence or intentional misconduct of city staff, as determined by court judgement.

2. APPLICANT INFORMATION

Last Name, First Name:*

Billing Address - Street, Apt/Ste:*

Billing Address - City, State, Zip Code:*

Primary Phone Number:*

Alternate Phone Number:

E-mail Address:

Identification - Document Type:*
Document Number (ID):*

Issued By (State or Country):*

Previous Service Address with SCMU

I DECLARE UNDER PENALTY OF PURJURY THAT 1) I AM THE RESPONSIBLE PARTY AT THE SERVICE ADDRESS AND/OR AN AUTHORIZED REPRESENTATIVE OF THE BUSINESS, AND 2) THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.

3. OFFICE USE ONLY

Account # --- Meter # --- Location
Deposit Receipt # --- Field Remarks