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Revised 11/13/2024 PUBLIC WORKS DEPARTMENT 80 Columbia Ave (360) 363-8100 Marysville, WA 98270 (360) 651-5099 Fax Water and Sewer Conservation Rebate 40143410.549070 Customer Account # Service Address Marysville, WA 9827 Mailing Address for rebate check if different than service address Phone Number Customer’s Signature Date Signed Approved Fixture Checked by Customer’s Verified Cost City Allowed Rebate Low Flow Toilet $ $ Low Flow Shower $ $ Tumble Action Washer $ $ $ $ TOTAL ($50.00 maximum rebate) $ $ Inspected by Date Inspected Supervisor Date Approved Posted to Account Date Posted Check # *Attach Receipts Date Paid