Application for Sonoma County Agriculture Access Verification Card

SONOMA COUNTY SHERIFF / DEPARTMENT OF AGRICULTURE/WEIGHTS & MEASURES

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Instructions:

Thank you for your interest in the Agricultural Access Verification Card Program.

Your application will be reviewed in the order received. Once your application has been reviewed, you will receive a separate email notifying you of your application status (approved, denied, appointment needed, or on hold pending additional information) and additional instructions.

For information regarding the Agricultural Access Verification Card Program, including eligibility and authorization requirements, please visit https://sonomacounty.ca.gov/AWM/AgAccess.

Agricultural Operation

* = Required Field

Nature of Operation:

Commercial Plant Agriculture Producer

Commercial Livestock Producer

Proof of Eligibility Provided by Applicant:

Operator Identification number

Certified Producer Certificate

CDFA Organic Registration

Agricultural land lease documentation

IRS Schedule F

USDA FSA documentation

CDFA Bureau of Livestock Identification

While the Department of Agriculture/Weights & Measures accepts this form of Proof of Eligibility, the document(s) selected will need to be provided to Department staff for review and verification. Document(s) will be reviewed in person during a scheduled appointment and immediately returned to the applicant. Document(s) will not be kept on file by the Department.

Please complete and submit application and you will be contacted by Department staff to schedule an appointment.

Operator Identification number (Last six digits of ID number):

Certified Producer Certificate:

CDFA Organic Registration:

Critical & Essential Activities to be performed:

Irrigation

Livestock Care

Refueling

Support to First Responders

Harvest and Related Activities

Other

Other Critical & Essential Activities:

Primary Location (be as descriptive as possible, including, at minimum, an address):

Additional farm or ranch address 2:

Additional farm or ranch address 3:

Additional farm or ranch address 4:

Additional farm or ranch address 5:

Additional farm or ranch address 6:

Additional farm or ranch address 7:

Additional farm or ranch address 8:

Additional farm or ranch address 9:

Additional farm or ranch address 10:

Additional farm or ranch address 11:

Additional farm or ranch address 12:

Additional farm or ranch address 13:

Additional farm or ranch address 14:

Additional farm or ranch address 15:

Additional Information / Notes (if needed):

Owner/Applicant Information

Is Property Owner/Operator currently the subject of a CalOSHA investigation for alleged violations of workplace safety regulations?

Yes

No

Provide additional information about alleged violations of workplace safety labor regulation:

Is the Owner and Applicant the same person?

Yes

No

Property Owner/Operator/Business Name

Property Owner/Operator Phone Number

Property Owner/Operator Address

Applicant First Name

Applicant Last Name

Applicant Full Name

Email address of Applicant

Phone Number of Applicant

Address of Applicant As a representative of an employer, employees should list their employer's business address, not their home address.

Applicant Title

Relationship of Applicant to Owner/Operator

Proof of Employment Upload (Letter of Authorization) Direct full-time employees must provide a signed letter of authorization

Training Certificate

Upload a Headshot Photo for ID

Certification and Acknowledgement

I am the Applicant or Owner/Operator.

I certify that the information provided in this form is true and correct, to the best of my knowledge. I certify that I am the agriculture farm owner-operator/livestock producer or am authorized on behalf of the agricultural operations owner-operator to voluntarily submit this form. I acknowledge and understand that the Sonoma County Department of Agriculture/Weights & Measures has the authority to verify whether a commercial agricultural operation exists at the described location. I acknowledge and understand that access to restricted areas is subject to the jurisdiction and orders of law enforcement, fire services, emergency services, and the California National Guard. I acknowledge and agree that I and any persons who access restricted areas will follow all orders of those agencies regarding entry and exit from the property, and all other laws and regulations applicable to the commercial agricultural operation, including workplace safety laws and regulations. I acknowledge and understand that an Agriculture Access Verification Card, if issued, does not certify compliance with any applicable laws or regulations, including workplace safety laws or regulations, nor does it guarantee access to any location. I further acknowledge and understand that an Access Verification Card does not require the holder to work in an area subject to an evacuation order.

Indemnification, Defend, and Hold Harmless Agreement

I acknowledge and understand the inherent risks and hazards associated with accessing restricted areas subject to official road closure as the result of a local emergency. I agree to indemnify, defend, and hold harmless the County of Sonoma and its officers, agents, employees, volunteers, or representatives from and against any liability, claims, actions, proceedings, losses, injuries, damages, or expenses, including as sociated litigation costs and attorney's fees, that may be asserted by any person or entity, including Applicant or agricultural operation owner/operator, arising out of or pertaining to the granting or denial of access. Further, I agree that I am solely responsible and must indemnify, defend, and hold harmless the County of Sonoma from any acts or omissions of the Applicant or agricultural operation owner/operator, his/her officers, agents, employees, volunteers, contractors, and subcontractors in accessing the above listed location. I further understand that if access is granted, then it is only to the location and for the activities identified above and the direct access route to and from that location; stopping along access routes, wandering, or loitering or performing activities other than those listed is strictly prohibited.

Applicant and agricultural operation owner/operator certify that they have carefully read the above Certification and Acknowledgement. Applicant and agricultural operation owner/operator further certify that they have carefully read the Indemnification, Defend and Hold Harmless Agreement and agree to be bound by it. Agriculture operation owner/operator further agrees to notify the Sheriff if and when the employee is separated from this employment.

I have read and agree to the above *

Signature

Signature Date

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Agricultural Access Verification Card Program Application / Programa De Tarjeta de Verificación de A

Agricultural Operation

Owner/Applicant Information