CITY OF CENTRAL POINT
Public Works Department
140 S. 3rd Street
Central Point, OR 97502
541-664-3321
Fish Friendly Car Wash Kit Check-Out Agreement
Event Location
Business Name:
Personal Info
Person Checking out Kit:
Phone: Phone:
Street Address: Street Address:
Site Approval from
Owner?
□
Yes
□
No
City, State & Zip:
Date of Event:
Time of Event
(duration):
Kit #:
Can the car wash runoff be discharged to a sink or sewer clean out?
□
Yes
□
No
If not, is there a nearby landscaped area the water can be discharged
to and do you have that property owner’s permission?
□
Yes
□
No
Contact Person at
Event (name):
Contact Person at Event (cell
pho
ne number):
The City of Central Point is s
upplying the organization and/or individual identified above with equipment needed to
prevent c
ar wash wastewater from entering the storm drain system. The person(s) checking out this equipment agrees
to follow the car wash kit set up
instructions. Equipment must be returned within 5 days of the date checked out from
the City unless otherwise authorized by the City of Central Point Public Works staff. The equipment must be returned
clean and any equipment failures brought to the city’s attention upon return. Failure to return the kit will result in the
person being billed for the cost of the kit. The kit may be returned to city hall, Monday - Friday, 8:00 – 4:30 p.m.
By signing this agreement, I agree to indemnify and hold the City of Central Point, its elected officials, officers, agents,
and employees, harmless from and against any liability or costs arising from or resulting from this agreement or the
use of the equipment. Further, by signing this agreement, I verify that I am an adult and am aware of the potential
hazards of working with electrical equipment and am responsible for the safe operation of said equipment.
For more information, contact Mike Ono in Public Works at (541) 664-7602 Ext. 243
Signature ________________________________________ Date Out _______________
Post Event Information:
Date Returned_____________ Number of Cars Was
hed (Approx) _________
Did the CAR WASH KIT work properly? Yes ______ No _______
Comments/Concerns:
_______________________________________________________________
____________________________________
___________________________________________________________________________________________________
OFFICE USE ONLY
Staff Chec
king Kit OUT: ______________________
Staff Checking Kit IN: ________________________
PLEASE FORWARD
the original signed copy to: Public
Works Deptartment
