Southwest Environmental, Inc

West Basin Toilet Distribution Program Registration Form

Date of Distribution Event will be: Saturday, February 27th 8am to 11am

Distribution is on a first come first serve basis. No walk-ins will be accepted. Toilets are available in limited quantities.

Must be a resident of Culver City, El Segundo, Malibu, Marina Del Rey, unincorporated areas of North Ladera Heights or Baldwin Hills, or Golden State Water Company or California American Water customer; AND
Must pre-register by calling (866) 931-3494 or online at www.swe-inc.com;
Must bring a copy of your most recent water bill;
Must bring a current driver's license;
Must install new toilet(s) and return old toilet(s) at recycling event on Saturday, March 13th, 2010
LIMIT 2 toilets per home, condo, or apartment unit.
*If you already have 2 ultra-low flush toilets installed, you cannot participate. Verification will be conducted at event. Existing toilets of 1.6 gpf or less do not qualify for this exchange program.

For more information please call toll free 1- 866-931-3494

Please fill out all fields, as all fields are required. If you are approved for the toilet exchange program, you will receive a certificate that you must print out and bring with you to the recycling event.

* PLEASE NOTE * If there is a counter top over the toilet, please call Southwest Environmental at 866-931-3494 in order to pre-register.

Contact Information

First Name

Last Name

Address

City

State

Zip

Phone

Water Retailer

Name on Water Account

Water Account Number

California American Water Company

Golden State Water Company

City of El Segundo

California Water Service Company

LA County Waterworks

HET Pre-Screen Information

Total number of toilets
(limit two (2) toilets per household)

1 2

Toilet #1

If there is a counter top over either toilet, please call Southwest Environmental at 866-931-3494 in order to pre-register.

* Does existing toilet have markings indicating 1.6gpf?	Yes No
* Was the building constructed before 1994?	Yes No
Have the existing toilet(s) been replaced since 1994?	Yes No
If there is a counter top over the toilet, is it less than 32"?	Yes No

* Toilets that were manufactured in 1994 or later are stamped or marked (at the back of the seat) 1.6 gpf or 6.0 lpf (liter per flush)

Toilet #2 (if applicable)

* Does existing toilet have markings indicating 1.6gpf?	Yes No
* Was the building constructed before 1994?	Yes No
Have the existing toilet(s) been replaced since 1994?	Yes No
If there is a counter top over the toilet, is it less than 32"?	Yes No

* Toilets that were manufactured in 1994 or later are stamped or marked (at the back of the seat) 1.6 gpf or 6.0 lpf (liter per flush)

Current Toilet

If unknown write unknown.

	Make (if unknown write unknown)	Gallon Per Flush (GPF)
Toilet #1
Toilet #2

Building Type

Single Family Home
Apt/Duplex/etc.

Is there more than one Apt or building on this account? yes no

If yes, how many?

Property Owner Liabilty

Property owner fully understands and accepts liability for payment if it is determined that a toilet consuming 1.6 gpf or less is replaced through this exchange program I Accept

Property owner fully understands and accepts liability for payment of HET if they do not return with old toilet(s) for the toilet recycling event I Accept