Customer Order Form - County Of Los Angeles Department Of Public Works, Waterworks Division

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COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS

WATERWORKS DIVISION

CUSTOMER ORDER FORM

1-877-637-3661

900 S. Fremont Avenue

260 East Avenue K8

23533 Civic Center Way

Alhambra, CA 91803

Lancaster, CA 93535

Malibu, CA 90265

(626) 300-3335

(626) 300-3385 FAX

(661) 723-7027 FAX

(310) 317-4674 FAX

NOTE: Where there has been a change in property ownership or tenancy, thereafter, the water service is temporary and subject to shut off without further notice pending satisfaction of

Waterworks Division requirements. The water service can only become permanent upon satisfaction of Waterworks Division requirements, including payment of outstanding bills,

completion and signing of this form, and presentation of verifiable proof of ownership.

SERVICE ADDRESS: ____________________________________________________CITY:__________________________________ACCOUNT NO._____________________

DO YOU HAVE (OR EVER HAD) A WATERWORKS DISTRICT ACCOUNT: ____YES ____NO IF SO, ADDRESS ____________________________________________

This is a "Customer Order Form for the County of Los Angeles Department of Public Works Waterworks Division" which is to be completed and signed by the owner of the property (and

the payer under certain conditions). The purpose of this form is to provide the Waterworks Division with correct billing information and to notify the property owner that he/she is

ultimately responsible for the water bill for the property in accordance with Rules 1-H-22, 1-H-25d, and 1-H-26d of the Rules and Regulations of the County of Los Angeles Department

of Public Works Waterworks Division as given on the reverse. The Customer Order Form must be completed, signed, and received by Waterworks Division, including an acceptable

document verifying proof of ownership, before permanent water service can be provided. Owner identification with signature is also required. In the event a properly signed form is not

on file with the Waterworks Division, the water service will be subject to discontinuance without further notice. The owner may request that the bill be sent to someone else, such as the

tenant designated as the payer. If this is the case, the payer is also to sign the form before it is returned to Waterworks Division. However, the owner shall be responsible for the bill

at all times.

NOTE: Tampering with Waterworks Division equipment may result in meter removal and the requirement that repair charges be paid before service will be restored.

I (WE) THE OWNER (S) OF THE PROPERTY AT THE GIVEN ADDRESS AGREE TO ACCEPT RESPONSIBILITY FOR PAYMENT

OF THE WATER BILLS FOR THIS LOCATION EVEN IF THE DESIGNATED PAYER DOES NOT PAY THE BILL.

PRIMARY OWNER (PLEASE PRINT)

DRIVERS LICENSE NO. STATE

SIGNATURE

SECONDARY OWNER

DRIVERS LICENSE NO. STATE

SIGNATURE

MAILING ADDRESS

CITY

STATE

ZIP CODE

PRIMARY TELEPHONE NO.

CELL NO.

BUSINESS NO.

PURCHASE DATE

DATE SIGNED

EMAIL ADDRESS:

Enclose either a copy of the recorded Grant Deed or another equivalent document acceptable to Waterworks Division verifying the Owner's interest in the property. If a Deed or

other document is not available due to recent purchase, a letter from the Escrow Company stating that the Deed has been recorded transferring interest and giving recording date

and names of prior and new owners will be accepted on a temporary service basis for up to sixty (60) days pending receipt of the copy of the recorded Deed.

I, (WE) THE TENANT/PAYER AM (ARE) AWARE THAT THE OWNER HAS DESIGNATED ME (US) TO RECEIVE AND TO PAY

THE WATER BILL FOR THIS LOCATION.

TENANT/PAYER NAME (PLEASE PRINT)

DRIVERS LICENSE NO. STATE

SIGNATURE

SECONDARY TENANT

DRIVERS LICENSE NO. STATE

SIGNATURE

MAILING ADDRESS

CITY

STATE

ZIP CODE