COUNTY OF LAKE



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| |SPECIAL DISTRICTS ADMINISTRATION | |

| | |230 N. Main Street |

| |LETTER OF RESPONSIBILITY |Lakeport, California 95453 |

| | |Telephone 707-263-0119 |

| |Lake County’s Water Agency |Fax 707-263-3836 |

This document is in lieu of a Renter’s Contract and Deposit

Today’s Date: _________________ Date the bank took ownership: ________________________

I, ____________________________ acting in my role as_________________________________

(name of signatory) (position)

for __________________________________ will take full responsibility of the water/sewer service

(name of company)

located at _____________________________________ in the city of________________________.

Phone Number:_____________________________________ Fax Number: ___________________

Mailing Address: __________________________________________________________________

(City) (State) (Zip)

Please read and initial

_____ Lake County Special Districts’ water and sewer bills that are not paid by the due date will have a late fee of $5.00/10% added to the account and a delinquent notice will be mailed. That delinquent notice will have a shut off date established. If the bill is not paid by 5 p.m. the day prior to the shut-off date, the service will be locked off and a fee (set by ordinances in each water district) will be charged. Call to make payment arrangements if necessary prior to the shut-off date.

______ I understand that billing begins from the date the bank took ownership until I give notice in writing ending service. I understand that if water is used by someone other than me between the time I vacated the premises and the time of my written notice to Special Districts, I am responsible for the bill and agree to pay same within 30 days.

______ If the final bill is not paid within 30 days, the account will be sent to a Collection Agency and reported to all Credit Bureaus.

______ This Account may be subjected to account setup charges or other charges pertaining to turning the water on and off. The charges are all itemized in the ordinances and Rules and Regulations which are posted on the internet or can be provided to you upon request.

I request that the water meter be ON OFF (Locked off with a padlock)

Other request (if any) _________________________________________________________________

BY SIGNING BELOW, I HEREBY AGREE TO ABIDE BY THE RULES AND REGULATIONS ESTABLISHED BY THE COUNTY OF LAKE FOR THE WATER DISTRICT.

____________________________________________ _________________________________________

Care of Date Approved By Date

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OFFICE USE ONLY:

Account Number:___________________________

Service Request Number ____________________

Set-up Charge NO / YES

Water ON Charge NO / YES

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