2. 
4. Name*
5. Business (if applicable)
7. Email Address (only used for sending customized recommendations following WaterSmart Check-up)
9. Phone Number*
10. Alternate Phone Number
12. Address of WaterSmart Check-up (Santa Rosa residents only)*
14. City*
15. State*
16. Zip Code*
20. If you are a requesting a WaterSmart Check-up at multiple locations, please include the additional addresses below.
22. Address
24. City
25. State
26. Zip Code
28. Address
30. City
31. State
32. Zip Code
36. Site Type
    -- Select One --HomeBusinessMulti-Family
38. Reason(s) for requesting a WaterSmart Check-up? (check all that apply)

    1. Indoor check-up
    2. Outdoor check-up
    3. Potential leak or high-water use
    4. I received a water waste tag
    5. Rebate information
40. Preferred time of day for WaterSmart Check-up? (check all that apply)

    1. Morning
    2. Afternoon
42. Additional Information
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field