MASSACHUSETTS WATER RESOURCES AUTHORITY

Water Conservation Fixture Request

Please print this form, fill it out and return by regular mail or fax to :
Elaine Donahue, MWRA Operations Planning, 100 First Avenue, Boston, MA 02129
Fax: 617 788-4888

Name: ________________________________________________ Phone (h): (___)___________

(w):(___)___________

Address: ______________________________________________

(select one)Arlington 
    
  Boston 
  Bedford 
  Belmont 
  Brookline 
  Cambridge 
  Canton* 
  Chelsea 
  Chicopee
  Clinton
  Everett Dedham*
  Framingham 
  Leominster 
  Lynn* 
  Lynnfield
  Lexington
  Malden 
  Marblehead 
  Marlborough 
  Medford 
  Melrose 
  Milton 
  Nahant
  Needham* 
  Newton
  Northborough* 
  Norwood
  Peabody*
  QuincyReading*RevereSaugus Southborough South Hadley FD #1SomervilleStonehamSwampscott WalpoleWalthamWatertownWakefield*Wellesley*Weston Westwood*WilbrahamWinchester*WinthropWoburn*Worcester
   

Are you the owner? _____ If no, please provide the following information:

(Tenants should have owner approval)

Owner's Name: _________________________________________________

Owner's Address: _______________________________________________

Owner's Telephone: (___)_________________________________________

List each property and apartment sequence separately and complete information below:

Number of: Living Units/Apartments: ______

How Many? Bathrooms: ____; Toilets: *_____; Showers: _____; Kitchens: _____

* Do you have a low-flow (1.6 gallon per flush) toilet(s)? ____yes _____no
Please be advised that toilet dams should not be used on low-flow toilets (installed after 1989).

Why do you want to install water saving fixtures? (check all that apply)

1. ___ Concern over water costs
2. ___ Fixtures are free
3. ___ Contribute to water conservation efforts
4. ___ Installation is easy
5. ___ Other, please specify: ____________________________________

How did you learn about this service?

1. ___ Media: ( television, newspaper, newsletter, etc.)
2. ___ Local water department
3. ___ Water bill insert
4. ___ MWRA staff
5. ___ Other, please specify:____________________________________

I certify that the above information is true. I will install the fixtures provided in a timely manner. I give the MWRA permission to verify that the fixtures have been installed.

Signed: _______________________________________________ Date: _______________