Drinking Water Program Application Bottled Water Application Coalition for Urban Rural Environmental Stewardship (CURES) Form 1: Application for Bottled Water - Well System Operator If you are a single residence/business with a well or residence/business receiving water from a small water system, click here for the proper form. The Coalition for Urban Rural Environmental Stewardship (CURES) has been awarded a grant for distributing funds to a commercial water purveyor who will provide bottled water to residences in the Salinas Valley Groundwater Basin whose domestic well water supply exceeds the drinking water standard for nitrates. CURES will not provide any information in this application to any local, state or federal agency involved with law enforcement or immigration enforcement. Eligible applicants are: Residences located in Salinas Valley Groundwater Basin whose domestic well has been verified to contain nitrate above the drinking water standard (A free water sample will be taken as part of this program); Those who complete this application (Forms 1-2); Those who sign a contract with a bottled water provider offered through this grant (specific details below). Successful applicants will be provided with bottled water delivery by Culligan of Monterey County through April 2019. Applicant must sign a separate agreement with Culligan and comply with all Culligan’s contract terms and conditions. Application (Form 1 and 2) must be filled in completely and submitted to CURES. Incomplete applications will not be reviewed. Applicant Contact Information(Main contact for phone calls and correspondence about this application) Water System Name or Number * Applicant(s) Name(s) * Address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip * Phone * Secondary Phone Email Address * Landowner Contact Information: Optional (if different than above) Landowner Name Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Phone Email Address Well Information(Please list wells below and answer the following questions) Do you have a domestic supply well that contains nitrates over the drinking water standard? Nitrates over drinking water standard? * Yes No Unsure If yes, date of last sample Nitrate Value (mg/L) If Known Nitrate Value (mg/L) If Known Nitrate Form Nitrate Form NO3 N How many residences are served by this well? Number of residences served How many people use this well water for drinking or cooking? Number of people drinking/cooking Coalition for Urban Rural Environmental Stewardship (CURES) Form 2: Agreement for Grant Funding of Bottled Water Please read this agreement carefully, as it provides an overview of the terms of the grant. This agreement must be signed by the Applicant and is required for funding consideration under this program. This signed agreement must be submitted for your application to be deemed complete. As the Applicant, you are responsible for completing the items outlined below. The undersigned Applicant understands, agrees to, and shall do the following for bottled water delivery: It is understood and agreed that, the Applicant will be required to: Sign this Agreement which will serve as a contract with CURES to allocate the funding for replacement bottled water, and; Sign the Culligan water provider contract, which will govern the terms and conditions of the service provided. Provide complete and timely information to CURES as requested to allow project completion. Allow reasonable access to CURES staff or their designees to the property for evaluation, maintenance and/or delivery purposes that do not interfere with the residence’s normal activities. Applicant understands that this information may be provided to the State Water Resources Control Board and/or Regional Water Quality Control Board to confirm CURES' compliance with the settlement agreement. Culligan water provider service agreements will be paid with the grant funds through April 2019 unless funding is extended by the project funders. This Agreement is effective only upon approval of the application by CURES. The term of this agreement commences upon the date of first water delivery. By entering my name in the applicant signature box below, I agree that my signature is on this application. Applicant Signature * Applicant Signature Applicant Name * Applicant Name Date * Date Landowner Signature Landowner Signature (optional) Landowner Name Landowner Name (optional) Date Date Well ID * If you are human, leave this field blank. Submit Copyright 2017 - Cures
