4040 Paramount Blvd.
Lakewood, CA 90712
CENTRAL BASIN WATERMASTER
ADMINISTRATIVE BODY
Request for Carryover Conversion
CONTACT INFORMATION
Central Basin Judgment Party Name:
Contact Name:
Address:
City:
State:
Zip:
Email:
CARRYOVER CONVERSION REQUEST
QUANTITY OF CARRYOVER CONVERSION REQUESTED:
ACRE-FEET
REQUEST ACCESS TO COMMUNITY STORAGE POOL IF REQUESTED CARRYOVER
CONVERSION EXCEEDS INDIVIDUAL STORAGE ALLOCATION (CHECK YES OR NO)?
YES NO
ADMINISTRATIVE YEAR FOR CARRYOVER CONVERSION TO OCCUR (i.e. 2016/17):
(Administrative year is from July 1 to June 30)
Name of Authorized Representative (Print):
Signature of Authorized Representative:
This request may be signed by the parties by facsimile, electronic or digital signature, and such signature shall be
deemed valid and binding on the party signing this request in that manner.
Date:
***FOR WRD USE ONLY***
Date Received:_______________________________________________________________________
Received by:_________________________________________________________________________
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