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Federal Tax Rebate Check - DOC

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					                                                                                                                                INDUSTRIAL WASTE SECTION
                                                                                                               1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                    www.lacsd.org

                                                                                                                                                JAMES F. STAHL
                                                                                                                               Chief Engineer and General Manager

                                           Santa Clarita Valley
                                 Automatic Water Softener Rebate Program
                                                                APPLICATION FORM
Please complete both sections of this Application Form, sign it, and send it (along with a receipt or rental contract for an alternative unit if applying for the
$150 rebate) to: LACSD, P.O. Box 4998, Whittier, CA 90607, Attn: Automatic Water Softener Rebate Program


Type of Rebate:        $100 for Automatic Water Softener Removal                         $150 for Removal and Replacement with Qualified Alternative Unit
Property Type, check one:        Detached Home           Attached Home          Condominium           Mobile Home         Apartment         Check one:
                                 (Single Family)        (Up to Four-plex)                                                                      Owner Occupied
                                                                                                                                               Renter Occupied

                                                         SECTION 1 – Customer Information
First and Last Name

Address Where Item Was Installed                             Apt. or Space #      City                                              State          Zip Code


Home Phone No. (        )        -           Daytime Phone No. (    )        -
TYPE OF AUTOMATIC WATER SOFTENER REMOVED (REQUIRED INFORMATION FOR PROCESSING REBATE)
Make & Model                                                                             Serial Number                                        Approx. Date Installed


FILL OUT THIS SECTION ONLY IF CHECK GOES TO SOMEONE OTHER THAN CUSTOMER ABOVE, OR TO A DIFFERENT MAILING ADDRESS
Name (first and last) or Business Name (if applicable) (rebate check should be made to)

Mailing Address (rebate check should be mailed to)          Apt. or Space #       City                                              State          Zip Code


IF CHECK IS TO BE PAID TO A BUSINESS:   Tax Status:                             Corporation         Non-Corporation            Exempt (e.g., Non-Profit)
 FEDERAL TAX ID OR SSN (FOR BUSINESSES ONLY)


                             SECTION 2 – Certification of Automatic Water Softener Removal/Disposal
If disposed by a resident, using the municipal trash collection service (Blue Barrel Disposal, Consolidated Disposal Service, etc.):
Name of Trash Collection Company                                                                                       Date of Pickup


If disposed by a third party (e.g., alternative vendor, licensed contractor, or owner of rental unit), have the third party complete, sign, and date
the following:

Company Name                                                                                                   Telephone No.
                                                                                                               (                )                  -
Company Representative                                                                                       Telephone No. (if different)
                                                                                                               (                )                  -
Address                                                                           City                                              State          Zip Code


Contractor’s License No.                                  Third Party Signature                                                             Date
Method of Disposal (i.e., landfill, salvage, resale out of Santa Clarita Valley, reinstallation out of Santa Clarita Valley)



                     READ THE TERMS AND CONDITIONS ON THE FOLLOWING PAGE AND SIGN BELOW
                             Questions? Call 1-877-CUT-SALT or visit www.lacsd.org/chloride
           I have read and understand the terms and conditions on the following page. I certify that the information I have provided is true and correct, the
SIGN       automatic water softener for which I am applying is eligible for this program, and that all automatic water softeners have been removed from the
           residence where the softener was installed. If I am applying for the $150 rebate, I further certify that I have installed a qualified alternative unit.
HERE
                Customer Signature                                                       Name (Please Print)                                             Date
Docs: 551492 (Rev. 04/11/2006)
                                          Santa Clarita Valley
                                Automatic Water Softener Rebate Program
                                                TERMS AND CONDITIONS
1.   I understand that this program is limited to one rebate per site address (location where the automatic water softener is installed),
     either the $100 Rebate for Removal of Automatic Water Softener OR the $150 Rebate for Removal of Automatic Water Softener with
     Replacement Using an Alternative Unit
2.   I understand that the rebate program is limited to residents and businesses that own or manage rental properties.
3.   I have not previously applied for a rebate under this program.
4.   The water softener for which I am applying is an automatic water softener, the kind to which rock salt or potassium chloride is added.
     I understand that portable exchange tank units, which are rental units where the softening tank is exchanged periodically by a
     service provider for a new softening tank, are not eligible.
5.   The automatic water softener for which I am applying is installed in a residential unit (house, multiplex, condominium, apartment, or
     mobile home).
6.   The automatic water softener for which I am applying is located in a residence served by the Santa Clarita Valley Sanitation District
     of Los Angeles County (formerly Sanitation District Nos. 26 and 32 of Los Angeles County). Residences outside of the Santa Clarita
     Valley or served by septic tanks are not eligible.
7.   I understand that it is illegal to install automatic water softeners in residences served by the Santa Clarita Valley Sanitation District of
     Los Angeles County (District).
8.   I understand that if the residence for which I am applying has more than one automatic water softener, all must be removed to be
     eligible for this rebate program.
9.   I understand that the automatic water softener for which I am applying must be disposed of ONLY by 1) the municipal trash
     collector for the residence where the softener is installed (Blue Barrel Disposal, Consolidated Disposal Service, etc.), 2) the
     installer of a qualifed alternative unit, 3) a licensed contractor, or 4) the owner of the unit (ONLY if the unit is rented or
     leased).
10. I understand that the program may be modified or terminated without prior notice. In the event that rebate amounts change during
    the program, the application postmark will be used to determine eligibility and rebate amount.
11. I will allow, if requested, District’s representatives reasonable access to my home to ensure that no automatic water softeners are
    present and, where applicable, a qualified unit has been installed, before a rebate is paid. I understand that a rebate will not be paid
    if I refuse to participate in any required verification. The verification of the removal/replacement must be scheduled within 30 days of
    customer contact by the District. I understand that the District may contact alternative unit providers and/or parties removing
    softeners to verify purchase and/or removal and may provide my name and/or address to complete the verification.
12. If I am a tenant or property management company, I am responsible for obtaining the property owner’s permission to take the
    measure for which I am applying for a rebate. My signature on this application indicates I have obtained this permission.
13. I am responsible for meeting all program requirements and complying with my state/county/city governments, property owner, and/or
    homeowners association requirements (if any) in my area regarding local conditions, restrictions, codes, ordinances, rules, and
    regulations concerning actions taken under this rebate program.
14. I understand that the District is not responsible for items lost or destroyed in mail/transit.
15. I agree that the selection of qualifying product(s), selection of manufacturer, dealer, supplier, remover, and/or installer, and purchase,
    installation, and ownership/maintenance of the qualifying products referenced in this application package are my sole responsibility
    and that my manufacturer, dealer, supplier, or contactor under this program is not an agent or representative of the District. I
    understand that the District makes no representation regarding manufacturers, dealers, contactors, materials, or workmanship. I
    also understand that the District makes no warranty whether express or implied, including without limitation the implied warranties of
    merchantability and fitness for any particular purpose, use, or application of the products or measures. With respect to any
    replacement water treatment units that I acquire, I agree that the District has no liability whatsoever concerning 1) the quality, safety,
    and/or installation of the products or measures, including their fitness for any purpose; 2) the workmanship of any third parties; 3) the
    installation or use of the products or measures including, but not limited to, effects on water quality; 4) any other matter with respect
    to the Automatic Water Softener Rebate Program.
     I hereby release the District, all other County Sanitation Districts of Los Angeles and their officers, agents and employees from and
     against any and all claims, demands, liability or loss arising out of activities conducted by or on behalf of the District in connection
     with my application for rebate under the Automatic Water Softener Rebate Program.
     I understand that I may hereafter discover facts different from or in addition to the facts that I now know or believe to be true. I am
     advised that California Civil Code Section 1542 provides as follows: “A general release does not extend to claims which the creditor
     does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have
     materially affected his or her settlement with the debtor.”
     I expressly waive and relinquish any and all rights; remedies and/or benefits I may now have or that may hereafter accrue in respect
     to the District’s Automatic Water Softener Rebate Program.

                   Questions? Call 1-877-CUT-SALT or visit www.lacsd.org/chloride

Docs: 551492

				
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Description: Federal Tax Rebate Check document sample