As a continuing LVMWD recycled water customer we ask that you assist with the required annual update of Site Supervisor information as it relates to your recyled water service. Please review the information and complete the form below.

We appreciate your cooperation.

Customer Name (required)

Account Number (required)

Site Supervisor Name (required)

Site Suprvisor Email Address (required)

Phone Number (required)

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Recycled Water Sute Supervisor Annual Certification Test

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As a condition of recycled water service to your site, you are required as Site Supervisor to correclty answer the following questions and return this test form to LVMWD

The Las Virgenes Municipal Water District must be notified ______ hours prior to the start of any recycled pipeline or irrigation system construction, installation or modification by calling (818) 251-2205, to schedule an inspection. (required)

When should inspections be made of new or replaced below ground piping? ________________ (required)

Is white PVC piping approved for use in any newly constructed, installed or modified recycled water irrigation systems? (required)

Yes

No

Which device is approved for use on a recycled water irrigation system? (required)

Hose bib

Quick Coupler

Both

Is recycled water approved for use in an enclosed private rear yard or patio in any case other than on a ranchette? (required)

Yes

No

A physical separation IS / IS NOT required between areas irrigated with recycled water and areas irrigated with potable water. (required)

IS

IS NOT

The _______________ should be familiar with the entire system within his or her responsibility and of all applicable conditions of non-potable water use and shall be responsible for the installation, operation and maintenance of system components, and for the prevention of cross connections with any potable water system on or off site. (required)

The Owner and ___________ shall be jointly responsible for the surveillance and proper operation of on-site recycled water distribution facilities to avoid cross-connections both on-site and with adjoining properties. Cross connection of the potable water system and the recycled water system is not to take place under any circumstances. (required)

Site Supervisor Name

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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