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WASTEWATER CAPACITY TRANSFER APPLICATION Please complete the following application to transfer Permitted Capacity. It should be noted that applicable Historical Capacity will be adjusted accordingly with the approved transfer of the designated Permitted Capacity. When complete, return to: City of Modesto, Water Quality Control Division, by mail at 1221 Sutter Ave., Modesto, CA 95351 or by fax to (209) 577-6290. Please call the Environmental Compliance Section at (209) 577-6377 with any questions or for assistance in completing the application. All transfers must meet the conditions of the most current adopted City of Modesto Ordinance or Resolution(s) governing the Capacity Bank Program. Name of Business: Address: City: Zip: Cross Streets: Assessor’s Parcel Number: Legal Name of Business Owner: Owner’s Mailing Address: Owner’s Phone Number: Owner’s Fax Number: Owner’s Email Address: Is this Business connected to the cannery segregation line: Yes ; No ; Unknown List amount of Permitted Capacity to be transferred in gallons of flow; pounds of BOD and TSS: Flow ; BOD ; TSS Applicant’s signature: Date: Print Applicant’s Name: Is the transfer of Permitted and/or Historical Capacity, any of the following: Please check the appropriate box(s). Sale Lease Loan Gift To the City of Modesto Between parcels owned by the same User A Corporate Affiliate of the User To other Users within the City’s Authorized Sewer Service District Area ---PAGE BREAK--- If the transfer of capacity is a Lease or Loan, what is the duration of the transaction? Please specify dates. To Permitted and/or Historical Capacity being transferred to the following User: Name of Business: Address: City: Zip: Cross Streets: Assessor’s Parcel Number: Legal Name of Business Owner: Owner’s Mailing Address: Owner’s Phone Number: Owner’s Fax Number: Owner’s Email Address: Is this Business connected to the cannery segregation line: Yes ; No ; Unknown List amount of Permitted Capacity to be transferred in gallons of flow; pounds of BOD and TSS: Flow; BOD; TSS; User’s Signature: Date: Print User Name: To be completed by City of Modesto: Is there a 1% surcharge? Yes No , If yes, surcharge capacity amount to Bank: Flow ; BOD ; TSS Administrative Transaction Fee: Approved By: Date: Print Name and Title: