San Joaquin County Delta Water Quality Coalition

San Joaquin County Delta Water Quality Coalition

Post Office Box 2357

Lodi, CA 95241‐2357

(209) 851-4204

2017 Annual Membership Statement

Invoice Date: Click here to enter text.

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Parcels Claimed / Click here to enter text.
Acreage Claimed / Click here to enter text.
Parcel Fee / $4.00 per acre
Total Due –
Acreage x Parcel Fee / $Click here to enter text.

Name and Address of person or entity enrolling parcels

Click here to enter text.

Contact Name Click here to enter text.

Email of Contact: Click here to enter text.

Phone Number: Click here to enter text.

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2017 Enrollment Fees: $4.00 per parcel acre; $50.00 minimum.

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The new General Order applies to irrigated lands that may discharge to surface water or to groundwater.

THIS FORM MUST BE SIGNED AND COMPLETED IN ORDER TO CONFIRM YOUR MEMBERSHSHIP IN THE COALITION

The undersigned owner and/or operator of irrigated farmland located within the geographic boundaries of the San Joaquin County and Delta Watershed understands that the Central Valley Regional Water Quality Control Board (Regional Board) has approved the San Joaquin County and Delta Water Quality Coalition (Coalition) as a proper third party for administering the new Waste Discharge Requirements General Order for growers in the San Joaquin County and Delta Watershed that are members of the Third Party (Order No. R5-2014-0029) (General Order).

The undersigned understands it is his/her responsibility to know and understand the terms and conditions of the General Order, and that failure to comply with the General Order may subject the owner/operator to removal from the Coalition, and potential Regional Board enforcement action.

The owner/operator understands that membership dues are to cover the cost of compliance requirements and administering the Coalition. The Coalition will provide a detailed accounting to members annually and upon request.

By signing below, the undersigned certifies he/she has read and completed the forms that follow this page and knowingly elects to participate in the Coalition and comply with the General Order.

SAVE THIS COPY FOR YOUR RECORDS

Member Signature: Date: Click here to enter text.

Email address: Click here to enter text. Phone Number: Click here to enter text.

Section A: All Members Must Complete

1.  The new General Order requires each member to maintain a copy of the General Order at the farm headquarters and be familiar with its contents. Please select the option to comply with this requirement.

☐ I will download the General Order document from www.sjdeltawatershed.org.

☐ Please send me a copy of the General Order via mail. A $30 fee will apply. Please enclose a check with fee payment.

2.  I am the landowner of all of the property enrolled in the Coalition on this invoice and I farm all of that property myself. None of the property is leased to or operated by others.

☐ Yes If you checked “Yes” – complete Table A.

☐ No Please Complete Section B and/or C.

Table A: Fill out this section if you are the landowner and farm the property.

Assessor Parcel Number(APN) / Parcel Acres / Irrigated Acres / Ag Comm. Restricted Materials Permitee # / Parcel Address / Assessee/Landowner
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Sections B and C instructions:

The General Order allows either a landowner or a lessee/operator to enroll property for coverage under the General Order, provided both the landowner and lessee/operator are kept informed of the General Order and its requirements. The General Order requires the member provide the contact information of the person authorized to provide access to the property for potential inspections for compliance with the General Order by Regional Board staff.

If you are a landowner who leases or contracts the farming of some or all of the enrolled property that will be covered by this invoice, complete Section B. If you are a lessee/operator of the enrolled property that will be covered by this invoice, complete Section C. Be sure to read and check the certification that follows each table.

Section B: To be completed by landowners who LEASE property that will be covered by this invoice to others to farm.

i.e. Landowner pays the enrollment fees for the property leased. Add additional sheets if necessary.

Please provide the information for the parcel and the contact information of person authorized to provide access to the property.

APN / Parcel
Acres / Irr. Acres / Name of Lessee & Contact Person / Mailing Address / Phone Number / Email Address
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☐ “I certify I have provided written notice to the lessee(s) or operator(s) of my enrolled properties in the Coalition under this order and have notified them of the order.”

Section C: To be completed by lessees/operators i.e. Lessee pays the enrollment fees for the property leased.

Add additional sheets if necessary.

APN / Parcel
Acres / Irr. Acres / Name of Landowner & Contact Person / Mailing Address / Phone Number / Email Address
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☐ “I certify I have provided written notice to the landowner(s) of my enrolled properties in the Coalition under this order and have notified them of the order.”

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