Toilet/ Urinal Rebate Program Residential/Commercial Application Form

TOILET/ URINAL REBATE PROGRAM RESIDENTIAL/COMMERCIAL APPLICATION FORM

PLEASE FILL OUT COMPLETELY

Water Account #: ______( ) Residential ( ) Commercial

Name:(please print) ______

Home Phone: ______Day Phone: ______Mobile Phone: ______

Installation Address: (New toilets must be installed at property address associated with Account # listed above.) ______

Condominium or Apartment Complex Name (if applicable): ______

Unit Number (if applicable): ______Lake Oswego, OR Zip Code: ______

Mailing Address (if different): ______

City: ______Zip Code: ______

E-mail Address: ______

TOILET REBATE SELECTION: Check one: ( ) $75.00 REBATE (replacing existing pre-1996 toilet w/new 1.6 gallon per flush model) ( ) $125.00 HET REBATE* (replace existing pre 1996 toilet with HET or dual flush model) ( ) $ 75.00 Low Flush Urinal Rebate: (Commercial) Urinal must use 1 gallon per flush or less. ( ) $125.00 High efficiency Urinal Rebate: (Commercial) Urinal must be ½ gallon / flush or less.

*HET Toilets must be certified as WaterSense High Efficiency Toilets. Look for the WaterSense label. A list of certified toilets can be found at http://epa.gov/watersense/product_search.html?Category=2 or call 503-675-3747.

New Toilet/Urinal Brand: ______Model Name & Number: ______Purchase Date: ______Purchased From: ______Installation Date:______New Toilet/Urinal Brand: ______Model Name & Number: ______Purchase Date: ______Purchased From: ______Installation Date: ______

STATEMENT OF ACCEPTANCE OF TERMS I have read and understand the Toilet Replacement Program Guidelines and limitations. I understand that I must recycle any replaced toilet or urinal so that they cannot be reused. I also understand that if requested, I will allow a City Staff person to schedule an appointment to visit my home/business and verify the information submitted with this application. Rebates will be on a first come first serve basis. I understand that this rebate program may be discontinued at anytime due to unavailability of funding, or other reasons as may apply and that approval of this application may not guarantee a rebate by the city in such cases.

Applicant’s signature: ______Date: ______

Please submit completed applications with copies of receipts no later than 90 days from the purchase date!

Submit to: Water Conservation Program Toilet Rebate City of Lake Oswego P.O. Box 369 Lake Oswego, OR 97034

H:\Water Conservation\Toilet Rebate Program\Toilet Rebate Application.doc

Overview: Commercial/Residential Toilet/Urinal Rebate Program

The City of Lake Oswego offers a Toilet Replacement Program that encourages commercial and residential water customers to replace their old toilets/ urinals with efficient water-conserving models to save water and money. Commercial businesses and residential property owners that receive water from the City of Lake Oswego may replace a maximum of two toilets or two urinals per account. Toilets being replaced must have been installed before January 1, 1996 and/or have a flush volume exceeding 1.6 gallons per flush. Qualifying urinals must replace existing urinals with a flush volume exceeding one (1) gallon per flush. Rebates are offered on a first come first served basis and will continue until current funding is exhausted.

Rebates:  $75.00 per toilet for 1.6 Ultra Low Flow standard model toilets and/or Urinals with volumes of one (1) gallon per flush or less.  $125.00 per toilet for High Efficiency Toilets (HET or dual flush models)* and/or Urinals with volumes of ½ gallon per flush or less. (No EPA standards for urinals) *ONLY HET or dual flush toilets certified by EPA WaterSense program will qualify for this rebate. Go to: http://epa.gov/watersense/product_search.html?Category=2 for a list of acceptable brands and models.

Application Guidelines: Commercial/Residential • Toilet/urinals(s) must be installed in a property/business that receives water from the City of Lake Oswego. • Toilets/urinals must be installed within 90 days of purchase. • Toilets must be purchased by the owner. • There is a limit of two toilets/urinals per business for rebate. • To receive the rebate, each new toilet must replace an existing toilet installed before January 1, 1996 and/or one that has a per flush volume exceeding 1.6 gallons. For urinals, each new urinal must replace existing urinals that exceed 1 gallon per flush. No rebates for new installations. • Old toilets/urinals cannot be reused. Participants agree to disable and recycle their old toilet(s). • Applications must be submitted with a copy of the sales receipt showing the toilet brand, model number (not SKU#) and proof of recycling.

Environmentally Conscious Recycling (ECR). The cost is $7.50 per unit. Request a scale ticket as proof of recycling. 12409 NE San Rafael, Portland, OR 97230, (503) 253-0867 [email protected]

S&H Landscaping. The cost is $10.00 per unit. Request a sales Receipt as proof of recycling. 20200 SW Stafford Rd, Tualatin, OR 97062, (503) 638-1011 http://www.shbark.com/

How to Apply:

1. Purchase toilet(s) or urinal(s). 2. Install within 90 days. 3. Download application from website: http://www.ci.oswego.or.us/publicworks/water-conservation-rebate-programs 4. Submit completed application with sales receipt and proof of recycling. 5. Schedule a time for verification. 6. Rebate will be generated within four (4) to six (6) weeks after verification and approval. (Rebate amounts will be credited to the water bill. Condo HOA members may receive a rebate by check.)

H:\Water Conservation\Toilet Rebate Program\Toilet Rebate Application.doc