Full Text
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 www.cityofmiddleton.us/waterconservation. Applicant Information Name (please print) Business Installation Address Unit Number Mailing Address (if different) Mailing Address City State Zip Telephone Account # Old Fixture Information Estimated tank size of toilet (gallons) being replaced (check one): o 1.6 gallons per flush o 3.5 gallons per flush o 5 gallons per flush Estimated water usage of spray valve being replaced (check one): o 2.5 gallons per minute o 5 gallons per minute New Fixture Information Is this rebate for a: o Toilet o Pre-Rinse Spray Valve o 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 o 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