Water Leak Rebate Form

Contact Information

First Name

Last Name

Account Number

Property Type

Address (as it appears on bill)

City

Phone Number

Email

How Did You Hear About this Rebate Program?

Rebate Information

Please provide us the following information relating to your treated leak and leak fix. We would like to know approximately when the leak started, when you identified the leak, and when the leak was fixed. Additionally, we would like a brief description of the leak and the summary for the repairs that were made to fix the leak.

Leak Begin Date

Leak Identified Date

Leak Repair Date

Describe Leak and Repair

Rebate Eligibility Requirements

You must acknowledge the following requirements

I certify that I am a Placer County Water Agency treated water customer.I certify that I have read the Treated Water Leak Rebate Requirements.I certify that I have proof of the leak prior to repairs being made.I certify that I have receipts/invoices for the repairs.

Provide Attachments

Note - Image file formats are preferred (eg. JPG, PNG) for uploads. PDF files and Word Documents can be uploaded too but they must be less than 4 MB in size. If you are unable to attach the correct file type, or if any other issues with the attachments arise, you may select the box below and submit the files in an email.

Optionally, check here to email receipts and photos instead. Send email with attachments to rebates@pcwa.net with your name and account number in the subject line. Failure to do so may result in a delay or rejected application.

Attach Receipt(s)

Drag & drop

your receipt(s) here or click to browse

Attach Water Leak Photo(s)

Drag & drop

your water leak photo(s) here or click to browse

Attach Repaired Leak Photo(s)

Drag & drop

your repaired leak photo(s) here or click to browse

Acknowledge Terms & Conditions

I have read, understand, and agree to the Placer County Water Agency Treated Water Leak Rebate Terms and Conditions.

I understand that PCWA reserves the right to have an Agency representative verify the installation of the product(s) at the service address on the application.

Check here to acknowledge terms and conditions

Release of Liability & Signature

Placer County Water Agency (PCWA) reserves the right to deny an application of any participant who does not meet all requirements as outlined. PCWA reserves the right to change the terms of this program at their discretion. PCWA cannot guarantee that the installation of the product(s) will result in lower water utility costs. The number of rebates is dependent upon the availability of program funds. Applications will be processed when all required information is provided by the applicant on a first-come, first-served basis.

You must sign this form by typing your name

Name

Treated Water Leak

Water Efficiency Rebate Form

Contact Information

Rebate Information

Rebate Eligibility Requirements

Provide Attachments

Drag & drop

your receipt(s) here or click to browse

Drag & drop

your water leak photo(s) here or click to browse

Drag & drop

your repaired leak photo(s) here or click to browse

Acknowledge Terms & Conditions

Release of Liability & Signature