1 - Eligibility Intake Form 2.0

Eligibility Intake Form

Technical Assistance Services for Mendocino County Cultivators
The Rural Resilience Project (RRP) Technical Assistance Services is open to eligible cultivators located in Mendocino County who hold either a provisional or annual outdoor or mixed light tier 1 license issued by the Department of Cannabis Control. Technical Assistance Services are limited to those with outdoor or mixed light tier 1 cultivation canopy areas of 10,000 square feet or less, although cultivators with ownership or financial interest in up to 20,000 square feet may also qualify.

Funding provided by CDFW Cannabis Restoration Grant Program.
Based on the Intake Form, which service categories are recommended?

A (LSAA (Extensions, Amendments, Reporting, Plans)B (Biological Assessment)C (Other Agency - County, Water Board, DCC)D (LSAA Supplies)E (Engineered Designs for LSAA Projects)F (Add to Review for Implementation Grant App)G (None, Education Series Only)H (TBD)
Cultivator Information

Please provide the name of the Designated Responsible Party (DPR) listed on your DCC (Department of Cannabis Control) license. This information helps us verify eligibility and ensure the designated individual is authorized to receive services.
DCC License Holder Name (Designated Responsible Party)*

First NameLast Name
Legal Business Name
Please use the Legal Business Name connected to the DCC license. https://search.cannabis.ca.gov/
UID
DRP Phone Number*
Please enter a valid phone number.
DRP Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diversity, Equity and Inclusion
Are you a Local Equity Entrepreneur Program (LEEP) verified cultivator?*

YesNoUnsure
If yes, what is your LEEP equity approval number?
If yes, please upload a copy of your LEEP approval letter.

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Is your cultivation site located within a disadvantaged community?*

YesNoUnsure
If you feel comfortable, please share your race or ethnicity with us.

African American/BlackAsianNative American/IndigenousPacific IslanderHispanic/LatinoMiddle Eastern/North AfricanWhitePrefer not to sayPreference not listed
If you are comfortable, please share your gender identity.

WomanManNon-binaryGenderqueer/GenderfluidPrefer not to sayNot Listed
Agent Consent

By completing this section, the Designated Responsible Party authorizes the appointed agent to act on their behalf in matters related to the services.
Agent Name

First NameLast Name
Agent Email
example@example.com
Agent Phone Number
Please enter a valid phone number.
Cultivation Site

Please verify that your cultivation site location and address are correct by using the mapping tool, linked below. Click on the link to open a separate window. Enter your cultivation site address into the search prompt. https://gis.mendocinocounty.org/portal/apps/webappviewer/index.html?id=255d7af6ece142b9962e92181d0f4ad9
Cultivation Site Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the Assessor Parcel Numbers (APNs) for the cultivation site address?*
If you cannot locate, use the link below to search by address - https://etrakit.mendocinocounty.org/etrakit3/Search/parcel.aspx
File Upload - DCC Premise/Property Diagram *

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What date was the Property/Premise Diagram or Site Map was last updated? *
Does the Diagram or Site Map reflect the current conditions?*

YesNoUnsure
Did you make any changes to the Cultivation Site after August 2023?

YesNoUnsure
Is your cultivation site located in a Cannabis Priority Watershed? https://waterboards.maps.arcgis.com/apps/View/index.html?appid=f109fd642aaa4fee9eb90f48475e0991

Eel RiverBig RiverNavarro RiverRussian RiverNot Listed
Landowner

For the cultivation site listed above, please submit the landowner information. If more than one landowner, list the names of all and contact details for one. If landowner is an entity, please list its name and the legal representative for the entity.
Is the Designated Responsible Party (DRP) the current landowner?*

YesNo
If not, provide the Landowner(s) name(s).*
If not, provide the Landowner(s) phone number.*
If not, provide the Landowner(s) email.*
Cannabis Cultivation Business License (CCBL)

The RRP Technical Assistance Services are available exclusively to cannabis cultivators in Mendocino County who hold an active provisional or annual license. Cannabis Cultivation Business Licenses (CCBLs) are issued by the Mendocino Cannabis Department (MCD). Previously, the MCD referred to CCBLs as a “local permit.” Currently, “application receipts” or “embossed receipts” are classified as “local provisional licenses,” while the “local permit” is now categorized as a “local annual CCBL.”
Is this cultivation site located in Mendocino County?*

YesNo
What type of Mendocino County Cannabis Cultivation Business License(s) (CCBLs) are held at this cultivation site?*

Type C (2,500sf) - OutdoorType C-A (2,500sf) - IndoorType C-B (2,500sf) - Mixed LightType 1 (5,000sf) - OutdoorType 1-A (5,000sf) - IndoorType 1-B (5,000sf) - Mixed LightType 2 (10,000sf) - OutdoorType 2-A (10,000sf) - IndoorType 2-B (10,000sf) - Mixed LightType 4-N - NurseryType 4-S - Seed Nursery
Do you have a local provisional authorization or annual Cannabis Cultivation Business License (CCBL) from Mendocino County at the cultivation site?*

Provisional (Application/Embossed Receipt)AnnualNo, I have not applied yet.Unsure
What are your Cannabis Cultivation Business License (CCBL) number at this cultivation site? *
What is your CCBL expiration date at this cultivation site?
Additional comments related to Cannabis Cultivation Business License (CCBL):
Department of Cannabis Control

The link below provides access to the official California cannabis license search tool, which helps verify and ensure accurate information about cannabis licenses issued by the Department of Cannabis Control. https://cannabis.ca.gov/resources/search-for-licensed-business/
What is the license term of the DCC cultivation license at this site?*

DCC Provisional LicenseDCC Annual LicenseDCC application submittedI have a Mendocino County CCBL only.
What is the license status of DCC cultivation license at this site?*

ActiveLimited OperationsExpiredRevokedSurrenderedSuspendedN/A
If your license status is not active, please explain.
Which type of DCC license(s) are held at this site located in Mendocino County?*

Specialty Cottage Outdoor (up to 2,500sf)Specialty Cottage Indoor (up to 500sf)Specialty Cottage Mixed-Light Tier 1 (up to 2,500sf)Specialty Cottage Mixed-Light Tier 2 (up to 2,500sf)Specialty Outdoor (up to 5,000sf)Specialty Indoor (501 to 5,000sf)Specialty Mixed-Light Tier 1 (2,501 to 5,000sf)Specialty Mixed-Light Tier 2 (2,501 to 5,000sf)Small Outdoor (5,001 to 10,000 sq ft canopy)Small Indoor (5,001 to 10,000 sq ft canopy)Small Mixed-Light Tier 1 (5,001 to 10,000 sq ft canopy)Small Mixed-Light Tier 2 (5,001 to 10,000 sq ft canopy)NurseryProcessorDistribution Transport OnlyOther
What is the DCC license number for the cultivation license selected above?*

0/13
What is the DCC expiration date for the cultivation license selected above?*
When does your provisional DCC cultivation license expire?*

Within the next 3 monthsWithin the next 6 monthsWithin the next 9 monthsWithin the next 12 monthsN/A - I have an annual DCC licenseI do not have a license yet
Are you a Designated Responsible Party (DRP), owner, or do you hold a financial interest in ANY other DCC cultivation licenses located anywhere else in the state?*

YesNo
If yes, please list the license type and DCC license number(s). *
For example: C11-0000045 (Distribution), C20-00000540 Medium Outdoor
Project Priorities

We understand that maintaining an ACTIVE license can be a complex process, with many potential challenges along the way. To better assist you, we’ve outlined common barriers that cultivators face. Please take a moment to select the items that are currently impacting your progress.
What barriers are you currently experiencing in maintaining an ACTIVE license?*

Biological AssessmentLake and Streambed Alteration Final Agreement (LSAA) Implementation ProjectsLake and Streambed Alteration Agreement (LSAA) Draft to Final AgreementLake and Streambed Alteration Agreement (LSAA) Required PlansLake and Streambed Alteration Agreement (LSAA) Extension or AmendmentSensitive Species Habitat Review (SSHR) project referral comments/recommendationsMitigation PlansCalFire Conditions of ApprovalMendocino County Compliance Plans (building permits, etc)Mendocino County Administrative PermitPower source (transition away from generator use)Mendocino County - Annual CCBL/Local Permit Not IssuedSite Map ModificationsWater Storage to Meet SIUR or LSAA diversion forbearance conditionsWater Board Required Plans (Site Management, Erosion Control, etc)N/AOther
Please upload any supporting documentation related to listed barriers. These may include Mendocino County Compliance Plans, Notice of Applicability, DCC Deficiency Notices, etc.

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Please detail any steps you are taking or plan to take to transition from a provisional or annual license.
Biological Assessment
Is a Biological Assessment required for your Cultivation Site?*

YesNoUnsure
If yes, where is the Biological Assessment requirement mentioned?

CDFW Sensitive Species Habitat Review - Project Referral CommentsCDFW Lake and Streambed Alteration AgreementMendocino County Compliance PlanDCC Deficiency NoticeUnsure
Has a Biological Assessment been completed at the Cultivation Site?*

YesNoUnsure
If yes, what is the current status?

Biological assessment completed, deemed sufficient to meet CEQA.Biological Assessment submitted to the DCC as Science Amendment.Biological Assessment completed, but concerned insufficient.Biological Assessment completed, but I have modified, expanded or propose changes to my cultivation area since conducted.Unsure
Please upload a copy of the Biological Assessment.

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For the Biological Assessment, have you modified, expanded or proposed changes to the cultivation site area after August 2, 2023?

YesNo
If yes, please explain the modification, expansion, or proposed changes to the cultivation site.
If the Biological Assessment Report was submitted to the DCC as a Scientific Amendment, please provide the date of submission.
Sensitive Species Habitat Review
Have you received a Sensitive Species Habitat Review (SSHR) Project Referral Comments document from CDFW?*

YesNoUnsure
Please upload a copy of the SSHR Project Referral Comments.

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Lake and Streambed Alteration Agreement (LSAA)

An LSAA "compliance plan" is any plan that was included in the reporting requirements of your LSAA, ie. water management plan, diversion infrastructure plan, bullfrog management plan, erosion control plan, annual diversion reporting, etc.
Which of the following was provided by CDFW in response to your Notification to CDFW:*

LSAA signed by CDFW (Final Agreement)Operation by Law (Op-Law) Letter signed by CDFWNo Notification Required from CDFWUnsigned Draft Agreement, "Incomplete" Notification response letter, or Other CDFW Response LetterUnsure
What is the EPIMS or 1600 Agreement Number on your Lake and Streambed Alteration document?*
Please upload a copy of CDFW's response to your Notification (Final Agreement, Draft Agreement, Op-Law, Incomplete notification response letter, or No Notification Required, or most recent communication to/from CDFW)*

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What is the Final Agreement or Op-Law Letter expiration date?
For the LSAA: Check the concurrence page (the last page of your agreement) to find the date it was signed, then add 5 years to determine the expiration date. If you don’t have a copy, you can email R1LSAEureka@wildlife.ca.gov and request the concurrence page.
When does the Final Agreement or Op-Law expire?

Within the next 6 monthsWithin the next 12 monthsWithin the next 24 monthsWithin the next 36 months
CDFW cannot extend or amend an Op-Law letter. If you have a Final Agreement, have you submitted:

“Request to Extend” to CDFW“Request to Amend” to CDFW
Were you provided an Extension letter signed by CDFW on letterhead?

YesNoUnsure
What project types are included in the LSAA?

Stream CrossingWater DiversionPond (Maintain or Remove)Sediment DeliveryOther
Are ALL of the projects included in your Final Agreement (and Amendment(s) or Op-Law letter COMPLETED?

All projects have been completed.Some or all projects are incomplete.
If you had to do "work" on a project per an LSAA, and the work is complete, did you submit a Project Inspection Report and receive a "Work Completed Letter" or other similar type letter from DFW. Did this letter get uploaded to the DCC portal and provided to the MCD?

YesNo
Select all of the LSAA projects that have been COMPLETED.

Stream CrossingWater DiversionPond (Maintain or Remove)Sediment DeliveryOther
Select all of the LSAA projects that are NOT COMPLETED.

Stream CrossingWater DiversionPond (Maintain or Remove)Sediment DeliveryOther
What is the status of your the LSAA compliance plans?

All plans are incomplete.Some plans are complete.All plans are complete.
Please let us know any additional comments about your LSAA.
Point of Diversion
Does your LSAA Final Agreement (and Amendment(s)) or Op-Law letter include a Point of Diversion?*

YesNoUnsure
If your site includes a Point of Diversion (POD) for cannabis or domestic use purposes, do any of these apply?

Water flow meter installed.Water flow meter not installed.All reporting requirements are current.Not current on reporting requirements.Unsure
If your site includes a Point of Diversion (POD) for cannabis or domestic use purposes, are you in the South Fork Eel Watershed? Please use the mapping tool to verify: https://waterboards.maps.arcgis.com/apps/View/index.html?appid=f109fd642aaa4fee9eb90f48475e0991

YesNo
Water Source
What is your current water source for cultivation?

Groundwater WellHorizontal WellSurface Water DiversionSpringPondMunicipal/County WaterIrrigation DistrictRainwater CatchmentWater DeliveryOther
What is your current water storage type and capacity?
For example: (6) 5000/gallon poly tanks = 30,000 gallons total
How many gallons of water do you use per year (average) on cultivation?
Please reference the annual water usage reported to the DCC and SWRCB (Water Board).
Have you implemented any rainwater harvesting systems?

YesNo
Do you have a dedicated fire water storage tank with nozzle?

YesNo
Provide any additional information or needs that you have regarding water source, storage and use, including storage capacity, water conservation and efficiency.
Challenges
To help us better understand the challenges you face as a licensed cultivator, please list the common barriers to your economic success.

Crop loss caused by pests or pathogens (e.g., Fusarium or russet mites)Compliance and licensing costs (Water Board, DCC, Surety Bond, Weighmaster, Local)Cost of laborCosts of supplies (Clones, soil, nutrients, etc)Lack of market accessLanguageLSAA projectsTaxesOther
What is your preferred language? (Please select the language you are most comfortable using.)

EnglishHmongMandarin/CantonesePomoPortugueseSpanishTagalongRussianVietnameseOther
To better serve you, please select any of the contractors you have received services from within the last two years.

Carlotta Curti, Yard to ZenHannah NelsonHigh Tide PermacultureLeach Water SystemsLoreto RojasMainspring ConsultingMunselle Civil EngineeringWRA
Please let us know any additional information you would like to share.
Cannabis Restoration Grant Program

Please indicate whether this Cultivation Site has previously participated in a CRGP-funded project or is currently pursuing CRGP funding. Note: Prior participation in a CRGP-funded project does not disqualify you from receiving Technical Assistance. Projects can be found here: https://wildlife.ca.gov/Conservation/Cannabis/Restoration-Grants#projects
Has this Cultivation Site benefited from a CRGP-funded project?

YesNoUnsure
If yes, please provide the following:
CRGP Funded Project Name and the Grantee (entity) administering the project.
Has an application for CRGP funding been submitted on behalf of this Cultivation Site?

YesNoUnsure
If yes, please provide any details (if known):
Application Name, Description of Projects Included, Organization or Consultant preparing the application
Attestation

By submitting below, I attest that the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may result in the denial of this application or termination of any assistance provided.I further acknowledge that submission of this application does not guarantee approval or receipt of Technical Assistance. I agree to comply with all program requirements and provide any additional information or documentation requested to support this application.I consent to the Rural Resilience Project (RRP) using the information provided in this application solely for the purpose of determining eligibility and administering Technical Assistance.
Form Submitted By

First NameLast Name
Should be Empty:

Eligibility Intake Form

Cultivator Information

Diversity, Equity and Inclusion

Agent Consent

Cultivation Site

Landowner

Cannabis Cultivation Business License (CCBL)

Department of Cannabis Control

Project Priorities

Biological Assessment

Sensitive Species Habitat Review

Lake and Streambed Alteration Agreement (LSAA)

Point of Diversion

Water Source

Challenges

Cannabis Restoration Grant Program

Attestation