[SUMMARY OF FINAL SUBMITTED VERSION]

SUPPLEMENTAL STATEMENT OF WATER DIVERSION AND USE FOR 2012

Primary Owner: Bank of the West, Trustee
Statement Number: S022507

1. Water is used under	Riparian Claim
2. Year of first use	1920

3-4. Maximum Rate of Diversion for each Month and Amount of Water Diverted and Used
Month	Rate of diversion (GPM)	Amount directly diverted or collected to storage (Gallons)	Amount beneficially used (Gallons)
January	0	0	0
February	0	0	0
March	0	0	0
April	0	0	0
May	0	0	0
June	0	0	0
July	166	1.5497945	1.5497945
August	166	2.0408185	2.0408185
September	166	1.626517	1.626517
October	166	1.26592125	1.26592125
November	0	0	0
December	0	0	0
Total		6.48305125	6.48305125
Comments

5. Water Diversion Measurement
a.	Measurement	Direct measurement using a device listed in Section 1 is "not locally cost effective" for water directly diverted and/or diverted to storage
b.	Types of measuring devices used
c.	Additional technology used
	Description of additional technology used
d.	Who installed your measuring device(s)
e.	Make, model number, and last calibration date of your measuring device(s)
f.	Why direct measurement using a device listed in Section 1 is "not locally cost effective"	Diversion is small or minimal in size Diversions are infrequent No power at diversion point
	Explanation of why use of devices and technologies listed in Section 1 are "not locally cost effective"	Water is only diverted from this location for dust abatement on logging roads used for timber harvest. As timber harvests only occur periodically in the area this diversion is only used periodically by the listed owner. There is no structure or power at the location of the diversion suitable for measurement using any of the methods listed above. When in use water is pumped directly from the watercourse into a water truck.
g.	Method(s) used as an alternative to direct measurement	Other
	Explanation of method(s) used as an alternative to direct measurement	The capacity of the water truck and the amount of time it takes to fill are used to determine the quantity and rate of diversion.

6. Purpose of Use
Other	Dust abatement

7. Changes in Method of Diversion

8. Conservation of Water
a.	Are you now employing water conservation efforts?	Yes
	Describe any water conservation efforts you have initiated	Roads are watered at night to prevent evaporative loss.
b.	Amount of water conserved	Acre-Feet
	I have data to support the above surface water use reductions due to conservation efforts.	No

9. Water Quality and Wastewater Reclamation
a.	Are you now or have you been using reclaimed water from a wastewater treatment facility, desalination facility, or water polluted by waste to a degree which unreasonably affects such water for other beneficial causes?	No
b.	Amount of reduced diversion
	Type of substitute water supply
	Amount of substitute water supply used
	I have data to support the above surface water use reductions due to the use of a substitute water supply

10. Conjuctive Use of Surface Water and Groundwater
a.	Are you now using groundwater in lieu of surface water?	No
b.	Amount of groundwater used
	I have data to support the above surface water use reductions due to the use of groundwater.

11a. Additional Remarks

Attachments
File Name	Description	Size
No Attachments

Contact Information of the Person Submitting the Form
First Name	Ryan
Last Name	Hilburn
Relation to Water Right	Agent
Has read the form and agrees the information in the report is true to the best of his/her knowledge and belief	Yes