Drinking Water Program Application Bottled Water Application Residence Coalition for Urban Rural Environmental Stewardship (CURES) Application for Bottled Water Apply online at https://www.curesworks.org/water/ The Coalition for Urban Rural Environmental Stewardship (CURES) is managing the Free Drinking Water Program, which provides water to residences located in Salinas Valley whose domestic supply well exceeds the nitrate standard for drinking water (10mg/L). CURES is contracting with Culligan of Monterey County to supply 5-gallon containers of free water to qualified applicants. Please be aware that SBASG and CURES are required to publicly report well water sample results and well locations. Well water sample results and location will be shared under an anonymous identifying code in order to protect the privacy of participants. CURES will not provide any information in this application to any local, state or federal agency involved with 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; 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 located in Salinas (at no cost to applicant). Applicant must sign a separate agreement with Culligan and comply with all Culligan’s contract terms and conditions. No costs will be incurred by any participant in this bottled water program. Application 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) Applicant(s) Name(s) * Is the applicant above the landowner? * Yes No 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 Water Use Information Water System Name * If you share your well with other residences, then the well may be a Water System monitored by Monterey County. Please enter your Water System Name here. Enter ‘Unknown’ if you do not know the name or are unsure if your well is part of a Water System. This is a: (Select One) * Residence Business If residence, how many people in household? If business, how many employees? Full-time: Part-time: Language Preference: * How did you learn about this program? (Select One) * Mailing Social Media Flyer Referral Other If you are human, leave this field blank. Submit Remove from Mailing List Remove from Mailing List If you would like to be removed from our mailing list, please complete this survey form. Name * Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip I am not interested in this program because (please check all that apply): * I have had my well tested recently and it is not high in nitrates. I am already receiving bottled water (note: we can take over your current water payments). I have a Reverse Osmosis (RO) system. I do not care if my well is high in nitrates. Other:Other: Submit Copyright 2017 - Cures
