2. Local Businesses - Apply for FREE toilet dye tabs and toilet flappers below.
4. Name*
5. Position/Title*
7. Business*
8. Email Address
10. Delivery Address (Santa Rosa Businesses Only)*
12. City*
13. Zip Code*
14. Name for Delivery*
18. Please enter number of free toilet dye tabs or flappers you want to be delivered to your facility
    Santa Rosa businesses only. Complimentary delivery may take up to 15 business days.
20. Toilet Flapper Quantity
    *Requires a phone call with you to confirm that we provide the correct flapper for your specific toilet.
21. Toilet Dye Tab Quantity
23. Additional Information

    1. Request information about FREE WaterSmart devices, services, and rebates.
25. Comments or Questions - We're here to help!
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27. 1. Receive an email copy of this form.
28. Email address

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