Water Conservation Fixture Request

Back to: Operation Watersense

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

(Please print)

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


Address: ______________________________________________

City/Town (From MWRA Water Community List only)  
*denotes partially supplied community


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: _______________

Rev. April 2, 2003 2:15 PM