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Special Event - Inside City

Application for Refuse Services ONLY

SERVICE LOCATION INFORMATION

Event Name

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Event Dates:

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Drop-off location - Street, Site:

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Drop-off location - City, State, Zip Code

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The applicant agrees to comply with the Conditions of Use issued by the City Manager's Special Events Office
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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.
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APPLICANT INFORMATION

Event Permittee Name:

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Event Coordinator Name:

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Mailing Address - Street, Apt/Ste
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Mailing Address - City, State, Zip Code
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Mobile Phone:

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Alternate Phone:
E-mail:
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ID - Document type
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ID - Document Number
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ID - Issued by (State or Country)

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I DECLARE UNDER PENALTY OF PERJURY 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. I ACCEPT RESPONSIBILITY FOR THIS UTILITY SERVICE AND AGREE TO ABIDE BY ALL RULES AND REGULATIONS ESTABLISHED BY THE CITY COUNCIL GOVERNING UTILITIES.
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