W hat is the Ultra Low Flush Toilet (ULFT) Program?
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For official Use Only 1 Service Request Number: 1) ________________ 2) ________________ 3) ________________ 4) ________________ (Please Print) ULTRA-LOW-FLUSH TOILET (ULFT) REBATE APPLICATION FORM Customer Name: Date: Service Address: Zip Code: Daytime Phone Number: Evening: Number of people living in dwelling: Year dwelling was constructed: Number of existing toilets in dwelling: _______________ Number of toilets being replaced: Date installed: _____________ Cost of new toilet(s): $ _________ (including sales tax and labor) Type of Dwelling: (Circle One) Residential – Multi-family – Commercial – Industrial – Institutional To qualify for a rebate, all of the following are required: ¾ The entire toilet must be replaced (both tank and bowl). ¾ A dated receipt of purchase for new toilet(s) must be attached to this application form. ¾ The replaced old toilet(s) must be destroyed. ¾ You must be replacing an older high flush volume toilet rated above 1.6 gallons per flush! I declare that I have installed or had the toilet(s) installed at the above address. Authorized Signature _______________________________________ Date: __________________________ * For Official Use Only * Da Date verified: Mail rebate check to:_______________________________________ Receipt(s) attached: Re Rebate amount $ Approved by: Date payment paid: Payment verified by: For more information call – (916)-774-5761 Mail rebate form to: Office hours are 8:00 a.m. to 5:00 p.m. – Mon. – Fri. Environmental Utilities FORM – 08433-1 Water Conservation Division Attn: Shane Reid 2005 Hilltop Circle Roseville, California, 95747 (See reverse side for qualifying information and instructions)
