Ariz. Admin. Code § tit. 18, ch. 4, art. 6, app B
Current through Register Vol. 30, No. 50, December 13, 2024
| Applicant Information: Name: Mailing Address Phone Number: Fax Number: E-mail: |
| Statement Information: 1) Name of Water System:__________________________________________PWS ID#_____________ 2) Ownership Type (Please check all that apply): ____Sole Proprietor ____Major Stockholders ____Board of Directors ____Cooperative ____Government Agency ____District ____Public Entity ____Corporation ____Limited Liability Corporation ____Other (please explain) _________________________________________________________________ 3) Name of Owner(s): (Check one) See below Attach a separate sheet if more space is needed Owner 1: Owner 2: Owner 3: 4) Agencies with rules applicable to the Water System: (Please check all that apply) ____Arizona Department of Environmental Quality ____Arizona Corporation Commission ____Arizona Department of Water Resources ____Arizona Department of Real Estate ____Arizona Department of Commerce ____Arizona Department of Agriculture ____Arizona Department of Corrections ____Office of the Fire Marshal ____Arizona Land Department ____Arizona Department of Revenue ____Arizona Department of Transportation ____Maricopa County Environmental Services ____Pima County Department of Environmental Quality ____Environmental Protection Agency Region IX ____Other(s) please specify___________________________________________________________________ page 1 of 2 |
| 5) Statement of Intent (Select one): ____It IS the intent of the owner or developer of this NEW CWS or NEW NTNCWS to transfer ownership of the water system. As part of the ownership transfer, it is understood that the owner or developer has a responsibility to disclose and transfer ALL information relevant to the construction and operation of the water system to the new owner. ____It is NOT the intent of the owner to transfer ownership of the NEW CWS or NTNCWS within one year of the completion of construction of the water system. 6) Date owner expects to begin operation: Month_________________ Day _____________ Year______________________ 7) Drinking Water Sources used: (Select all that apply) ____Ground Water ____Purchased Ground Water ____Surface Water ____Purchased Surface Water 8) Table of Contents of Systems Elementary Business Plan (Please check one): ____The Table of Contents of the Elementary Business Plan is attached. ____The Table of Contents of the Elementary Business Plan is summarized below. Summary______________________________________________________________ 9) Signature of each current owner: Check if additional signature page is attached.____ I agree to comply with the requirements of 18 A.A.C. 4, Article 6. Print Name:____________________________Signature:__________________________Date:___________ Print Name:____________________________Signature:__________________________Date:___________ Print Name:____________________________Signature:__________________________Date:___________ page 2 of 2 |
Ariz. Admin. Code tit. 18, ch. 4, art. 6, app B