Interruptible Reclaimed Water Service Application

Complete one application per meter

Organization*
Address*
Mailing Address (If different from above
Meter Number and Location:*

Primary Contact

Name*
Title*
Phone Number*
Email*
Cell Number*
*Cell numbers must accept text messages.

Contact For Interruption Notification (May indicate up to 3)

Name
Title
Phone Number
Email
Cell Number
*Cell numbers must accept text messages.
Do you have a 2nd Contact For Interruption Notification?
- Yes
- No

2nd Contact For Interruption Notification

Name
Title
Phone Number
Email
Cell Number
*Cell numbers must accept text messages.
Do you have a 3rd Contact for Interruption Notification?
- Yes
- No

3rd Contact for Interruption Notification

Name
Title
Phone Number
Email
Cell Number
*Cell numbers must accept text messages.

Accounting Contact

- SAME AS PRIMARY CONTACT
Name*
Title*
Phone Number*
Email*

Person Completing Application

- SAME AS PRIMARY CONTACT
Person Completing Name:*
Title*
Phone Number*
Person Completing Email Address*
Terms and Performance Guidelines*
ELIGIBILITY

The Interruptible Reclaimed Water Service program may not be offered every year.

Eligibility does not carry over to subsequent fiscal years. Customers must reapply each year, if the program is available.

All Long Beach Water Department (LBWD) regular reclaimed water customers are eligible to apply for the Interruptible Reclaimed Water Service program, unless customers are on non-peak or other special reclaimed water rates.

Criteria used for eligibility are annually subject to change.
CUSTOMER AGREES TO:

Submit one application for each reclaimed water meter the customer is offering for consideration of the Interruptible Service rate.
Acknowledge that the completion of the application shall constitute acceptance of the Terms and Performance Guidelines.
Upon notification, at the sole discretion of the LBWD and subject to inspection and verification, voluntarily cease any and all flows from the meter until notification from LBWD that service can resume at that meter.
Provide up to three contact email addresses as the sole communication points for the interruption notices. Customer may also provide cell phone numbers for each contact person. Phone numbers must accept text messages. Text messages may be sent by LBWD staff, notifying the customer that an email message has been sent.

Nothing in the provision of Interruptible Reclaimed Water service exempts a meter owner from complying with all other policies, rules, codes and guidelines established by the LBWD and City.

READ FULL TERMS AND GUIDELINES HERE
- I have read the Terms and Performance Guidelines
Signature (hard copy entries only):
Date Application Completed
MM slash DD slash YYYY
For a copy of your completed form, print before submitting application.
Print Form

Comments
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Interruptible Reclaimed Water Service Application

For a copy of your completed form, print before submitting application.

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