Document Middleton_doc_510292c77c

Middleton Water Utility High Efficiency Toilet and Pre-Rinse Spray Valve Rebate Commercial Application Form Please read all program rules before submitting. The rules can be found at http://cityofmiddleton.us/waterconservation. Applicant Information Name (please print) Business Installation Address _ Unit Number Mailing Address (if different) _ Mailing Address City State Zip Telephone Water Utility Account # Old Fixture Information Estimated tank size of toilet (gallons) being replaced (check one):  1.6 gallons per flush  3.5 gallons per flush  5 gallons per flush Estimated water usage of spray valve being replaced (check one):  2.5 gallons per minute  5 gallons per minute New Fixture Information Is this rebate for a:  Toilet  Pre-Rinse Spray Valve  Both New toilet manufacturer (brand) _ Model name _ Model number _ Purchase price New pre-rinse spray valve (brand) Model name Model number _ Purchase price Rebate Agreement  I have read, understand, and agree to the terms and conditions in the water conservation program description. The fixtures I have purchased comply with the City of Middleton Plumbing Code and the City of Middleton Cross Connection Ordinance. I understand that I must dispose of the old fixtures so that they cannot be reused. I understand and agree that the Middleton Plumbing Inspector upon prior notification to me may inspect the premises to verify installation of the rebated WaterSense fixtures. Applicant Signature Date _ Mail your completed application form and your original dated receipt to: Middleton Water Utility, Water Conservation Rebate Program, 7426 Hubbard Avenue, Middleton, WI 53562. Questions? (608) 821-8370