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

Multi-Family Residential - Inside City

Application for Water, Sewer, and Refuse Services

SERVICE LOCATION INFORMATION

Service Address - Street, Apt/Ste
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Service Address - City, State, Zip Code
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Total number of persons who permanently reside at the above service address

(A permanent resident is someone who resides at the service address for at least 21 days within each monthly service period.)

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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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Requested Service Start Date (no weekends or holidays):
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Number of dwelling units (Municipal Code requires one garbage cart per dwelling unit)
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Requested Refuse Cart Size (one cart per dwelling unit):
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Requested Dumpster Service (subject to approval by the Public Works Department):
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Dumpster Pickup Frequency
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Dumpster Placement (Street placement is not allowed unless approved by the Public Works Department):
What type of material will be in the Dumpster?
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.
I have read, understand, and agree with the above declaration.
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APPLICANT INFORMATION

First Name:

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Last Name:

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Billing Address - Street, Apt/Ste
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Billing Address - City, State, Zip Code
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Primary 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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Previous Service Address with SCMU
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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