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2. First Name*
3. Last Name*
5. Service Address*
7. City*
8. State*
9. Zip*
11. Account Number*
12. Phone Number*
14. Email*
16. How did you hear about this free leak kit?

    1. Website
    2. Customer Service Rep.
    3. Bill Insert
    4. Postcard
    5. District Event
    6. Neighbor
    7. Other
18. Terms

    Rancho Water does not warrant any aerator, dye tablets, toilet flapper, garden hose repair kit and/or hose nozzle to be free of defects or warrant the quality of the workmanship, and Rancho Water is not responsible for the suitability of the premise for aerator, dye tablets, toilet flapper, garden hose repair kit and/or hose nozzle  installation or use. The undersigned further agrees to hold harmless Rancho Water, its directors, officers, and employees against all loss, damages, expense, and liability resulting from any personal injury or loss including, but not limited to, thermal shock and scalding, destruction, or damage to property arising out of, or in any way connected to, the installation and/or use of the aerator, dye tablets, toilet flapper, garden hose repair kit and/or hose nozzle. Rancho Water does not guarantee that the installation of these devices will result in water savings. Availability is on a first-come-first-served basis and while supplies last. 

20. Electronic Signature*

    1. I certify that the information on this application is true and correct and that I have read, understand, and agree to the above terms
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit

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