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PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360) 363-8100 (360) 651-5099 Fax Revised 4/9/2010 Water and Sewer Conservation Rebate 40140580.549000 Customer Account Address Phone Approved Fixture Checked by Customer’s City Allowed Verified Cost Rebate Low Flow Toilet Low Flow Shower Tumble Action Washer TOTAL ($50.00 maximum rebate) Inspected Date Inspected Customer’s Date Signed Date Approved Posted to Date Posted Check Date Paid *Attach Receipts