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CVWD - Stub Out Staking Form 192 - 2023-12-07COACHELLA VALLEY WATER DISTRICT TRACT NO. DEVELOPER: Name of Firm Representative Mailing Address Telephone No. ( ) ENGINEER: Name of Firm Representative's Office Mailing Address Telephone No. ( ) Stub -out Connection Staking Information Form Known as I prefer that you contact the individual listed above to arrange for staking of the stub-out(s) location. Developer Li Date NOTE FOR THE DEVELOPER Engineer Digitally signed by Ubaldo Ayon �_ L • Jr � Date: 2023.12.07 09:23:04 -08,00, This form and the deposit for stub -out connection(s) must be either mailed or delivered to the district. Mail or hand delivery Hand delivery only Coachella Valley Water District Attention: Development Services Supervisor Post Office Box 1058 Coachella, California 92236 Coachella Valley Water District Attention: Development Services Supervisor 75-525 Hovley Lane East Palm Desert, California 92211 CVWD-192 (Rev. 9/06)