To apply for a
rebate, please complete the following form, print, and mail
or fax to the North Coast County Water District office. A
copy of your receipt for the purchase of your new toilet and a
copy of your receipt for the disposition of the old toilet are
required. Rebate application must be received within 90 days
of purchase.
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Shaded Areas for Official Use Only
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Applicant |
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| Applicants Name: |
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| Account#: |
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| Mailing Address of Applicant: |
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| Contact Person: |
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| Telephone#: |
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| Installation Address: |
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| Date of Purchase: |
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| Date of Installation: |
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| Number of Toilets Replaced: |
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| Make and Model of toilet: |
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| Installed by: |
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| Number of Persons Living in Household: |
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Note: For conservation monitoring
purposes, please notify NCCWD when household size changes. Is
this rebate for a singly family home, multi unit or commercial
property.(Please list here)______________________________
Year House
Built_________________Number of bathrooms in home:__________________
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| Date:__________ |
For Official Use Only
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Prepared by:
_______________ |
Total Allowable
Rebate:
____________ |
Authorized by:
____________ |
Mail to: NCCWD, 2400
Francisco Blvd. P.O.Box 1039, Pacifica,CA 94044-6039
or Fax: (650) 355-0735
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