South Lake Fire Safe Council, Lake County, California

•	The material must be stacked adjacent to roads and accessible to our contractor’s equipment without having to be moved.
•	The material must be free of rocks, dirt, berry vines, poison oak, tree stumps or construction material of any type. · Brush, tree limbs, and trees smaller than six inches (6”) must be stacked neatly and evenly with the butt ends all facing the road. Piles cannot exceed five feet (5’) in height.
•	Bulldozed piles or machine-stacked piles cannot be processed.
•	Piles cross-stacked or stacked so dense and compacted that the material cannot be pulled free to run through the chipper will not be processed.
•	Material must be cut to manageable twelve foot (12”) lengths maximum.
•	Do not submit this form until the material is stacked and ready for inspection.

Applicant must send in the South Lake Fire Safe Council Annual Membership Application Form and a donation of $25.00 with your first chipping request each year.
This yearly donation entitles members to up to two (2) chipping visits totaling no more than one-half (1/2) hour per year. Members will be charged $25.00 for each half-hour of chipping thereafter (for a maximum of two (2) hours per year total chipping.)

Applicant agrees to pay South Lake Fire Safe Council for
additional chipping not covered by the $25 membership donation
within ten (10) days of billing.

Pre-Inspector’s Notes: Photo: Yes (

) No (

)

Estimated Chipping Time: ___________ Actual Chipping Time: ___________

Support Membership No.: ____________ Chipping Time: _____________

For Office Use Only

Date Received _______ Date Entered _______ Date Inspected ________ Date Completed ________

South Lake Fire Safe Council
Right of Entry (Temporary)

Permission is hereby granted to the South Lake Fire Safe Council, its officers, employees, designees and/or permittees to enter upon our land for the purpose of chipping brush and
debris and all incidents thereto, pursuant to the requirements of the South Lake Fire Safe Council’s Chipping Program.

This is not a request for a permanent easement and/or right-of-way, and this permission will automatically terminate upon completion of the work.

INDEMNIFICATION-HOLD HARMLESS AGREEMENT

1	COUNCIL to indemnify OWNER against loss or damage caused by any wrongful or negligent act or omission of South Lake Fire Safe Council, its agents or employees in the course of their employment as may be provided for in the California Entity Tort Claims Act.
2	COUNCIL further indemnifies and holds harmless OWNER from any and all claims, lawsuits, losses and damages, brought for, or on account of, injuries to or death of any person or persons, arising out of, or alleged to arise out of, or resulting from its agents or employees on the property.

By: _____________________________________ _______________________________________
Owner’s Signature Print Owner’s Name

Address: _________________________________ _______________________________________
Street City/State

Telephone: _________________________

RECOMMENDED FOR APPROVAL:

By: ________________________________

Each time that you request chipping in a given year, you must mail in the Chipping Request Form and the Right of Entry Form to the below address. If it is your first chipping request of the year, you must also mail in your SLFSC Annual Membership Application Form and a $25 Annual Membership Donation the below address.

(Make your membership checks payable to: South Lake Fire Safe Council)
          SLFSC
          PO Box 1773
          Middletown, CA 95461

If you do not have one already, there are several ways to obtain an SLFSC Annual Membership Application Form:

Fill out a Membership Application Form at the Middletown Fire Station on Hwy. 175.

Call Elizabeth Solliday at (707) 355-5899 to request a Membership Application form (please leave your name and mailing address on her voicemail.

Pick up form at Cobb Area County Water District Office.

Go to www.southlakefiresafecouncil.org and print out a membership form, then mail to
          SLFSC
          PO Box 1773
          Middletown, CA 95461