Water Usage Approval Form

WATER USAGE APPROVAL FORM

Administrative Information

Parties

WHEREAS Recitals

WHEREAS, the Applicant, , has requested authorization to use water for the purposes set forth in this form and in related attachments;

WHEREAS, the Approving Authority is empowered to grant conditional approvals for water use subject to regulatory requirements, mitigation measures, payment of fees, and monitoring obligations;

WHEREAS, the parties desire to set forth the scope, payment obligations, term, and other conditions under which the water use is authorized;

Scope of Work

Location, Source and Volumes

Water Source(s): Municipal Groundwater Surface water Reclaimed/Reuse

Purpose and Conservation Measures

Environmental Assessment and Attachments

Required Attachments (check all submitted): Site map Monitoring plan Mitigation plan Other

Payment Terms

Fee Amount: payable as set forth below. Fees are non-refundable unless expressly stated by the Approving Authority.

Late Fee / Interest: In the event of late payment, the Applicant shall pay a late fee of on the outstanding balance, or the maximum permitted by law, whichever is less.

Term and Termination

Term Commencement Date: . Term Expiration Date:

Notice to Terminate: Either party may terminate this approval by providing written notice days in advance, except where termination is for cause as described below.

Confidentiality

The Applicant and the Approving Authority agree that information designated in writing as confidential by either party and provided in connection with this approval shall be maintained in confidence to the extent permitted by applicable law. Confidential information shall not include information that (i) is or becomes publicly available other than through breach of this agreement, (ii) is lawfully obtained from a third party without confidentiality obligations, or (iii) is independently developed without use of the other party's confidential information.

Representations, Indemnity and Warranties

The Applicant represents and warrants that all information supplied in this application and in any attachments is true, complete, and accurate. The Applicant shall indemnify, defend, and hold harmless the Approving Authority, its officers, agents, and employees from and against any and all liability, claims, damages, losses, or expenses arising out of the Applicant's use of water authorized by this approval, except to the extent caused by the gross negligence or willful misconduct of the Approving Authority.

Conditions of Approval

1. The approval is granted subject to compliance with the Scope of Work, conservation measures, monitoring requirements, and payment of fees set forth herein.

2. The Approving Authority reserves the right to modify or suspend this approval if monitoring indicates noncompliance or adverse environmental impacts.

3. All reports, monitoring data, and other required documentation must be submitted to the Approving Authority in the form and frequency specified in the approved monitoring plan.

Governing Law; Entire Agreement

Governing Law: This approval and any disputes arising out of it shall be governed by and construed in accordance with the laws of the state of , without regard to its conflicts of law principles.

Entire Agreement: This form, together with approved attachments and any referenced monitoring or mitigation plans, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior negotiations, representations, and agreements, whether written or oral.

Certifications and Acknowledgements

Applicant certifies that the information provided is true and correct to the best of their knowledge and agrees to comply with the terms of this approval.

False statements or omissions in this application may result in denial, revocation, civil penalties, or criminal prosecution under applicable law.

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