The City of Veneta is an equal opportunity employer and provider
8/5/2014S:\FORMS\Public Works\Bulk Water Application.doc
88184 8
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Street • P.O. Box 458 • Veneta, Oregon 97487 • Phone (541) 935-2191 Fax (541) 935-1838 • www.venetaoregon.gov
□ Individual □ Commercial □ Other _________________________
Name: _______________________________________________________________________________
Mailing Address: _______________________________________________________________________
Phone #: _____________________________ Alternative Phone #: ______________________________
Please list below any other individuals who are authorized to use your City of Veneta prepaid bulk water card.
Name: ______________________________________ Phone #: _______________________________
Name: ______________________________________ Phone #: _______________________________
I hereby apply for bulk water station privileges and a bulk water prepaid card. I acknowledge that there is a
$25.00 one-time administrative set up fee. I understand that I am required to prepay in order to use the bulk
water station. There is no restriction on the purchase amount; however, there will be a 2% surcharge (on the
purchase amount) each time the card is refilled. Use of the prepaid card will be charged a flat rate, to be set by
resolution of the City Council, per 1,000 gallons of water.
I understand that I can only prepay my bulk water card at the Veneta Administrative Center located at 88184 –
8
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St, Veneta, Oregon during the hours of 9:00 am to 4:30 pm Monday-Friday. Note: This City is closed most
federal holidays.
I acknowledge that the City will not refund or reimburse or reimburse for unused, lost, damaged, or stolen
cards. A $15.00 fee will apply for replacement cards. I agree to comply with all City of Veneta regulations
governing the operation of use of City water facilities and to notify the City of any change in authorized users. I
understand that the City will not be responsible for unauthorized use of my bulk water card.
I acknowledge that the City reserves the right to restrict water purchase quantities and that the City will not be
responsible for any consequences of the restrictions.
I acknowledge that I will be held financially responsible for any damage, alteration, or disturbances caused by
my use of the bulk water station.
________________________________________ ______________________
Applicant Signature Date
FOR CITY USE ONLY .
________ Application completed and signed _________ Card loaded
________ Collected $25 set-up fee _________ Prepaid card number
click to sign
signature
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