FIXTURE REPLACEMENT PROGRAM - HIGH VOLUME USER (HVU) REBATE SCREENING and APPLICATION FORM

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1 FIXTURE REPLACEMENT PROGRAM - HIGH VOLUME USER (HVU) REBATE SCREENING and APPLICATION FORM City of Ottawa Attn: WaterWise Program Infrastructure Services and Community Sustainability 951 Clyde Avenue Ottawa, ON 311 K1Z 5A6 Page 1 - Steps to receive the High Volume User Rebate 1 Review the Fixture Replacement Program - HVU Rebate Program Terms and Conditions. 2 Complete pages 1 through 3 inclusive, attach technical specification sheets and pre retrofit photos. 3 Submit to the address listed above via mail or hand delivery for review. Upon receipt of confirmation, proceed with fixture replacements. Work must be completed within 18 months of 4 approval. After completion of the retrofit work, complete page 4, attach legible copies of all original sales receipts, post retrofit 5 photos and the last twelve (12) months water billing. 6 Submit to the address listed above via mail or hand delivery. 7 At the City's discretion, allow City staff or designate to verify installations. Service (Facility) Address *Facility / *Facility Address OTTAWA, ON - Postal Code *Water Billing Account Number(s) *Last Name *Mailing Address - - x *Business Phone Number * required information Extension *First Name OTTAWA, ON - Postal Code Address All applicants for the City's Fixture Replacement Program agree to provide the City with access to water billing information for the participating facilities for the purposes of determining program effectiveness. Any information included in any publicly released analysis, study or report completed by the City will not include any personal or identifying information. I have read, understand, and agree to the terms and conditions of the City's Fixture Replacement Program. I acknowledge that all of the information provided in this application form is true and correct. Signature of Applicant / / dd/mm/yy If approved, rebate will be processed on the company's water billing account for the facility address indicated above. Personal Information on this form, including Water Billing Account Number, is required for the purposes of the City's Fixture Replacement Program, which is part of the City's Water Efficiency Plan as approved by City Council. Such personal information will be used for the purposes of administration and management of the Program. Questions regarding this collection may be addressed to: the Project Manager, Environmental Programs, Infrastructure Services and Community Sustainability, City of Ottawa, 951 Clyde Avenue, Ottawa, K1Z 5A6, telephone: (613) , Ext Disclaimer and Release The City makes no representation or warranty, express or implied, relating to any fixture or the availability, competence, workmanship or financial status of any installer, and by submitting this Application Form each Applicant will be taken to have fully and unreservedly released the City with respect to any claims for costs and liabilities in connection with the preparation for and/or the replacement of any fixture and the installation and/or use of any fixture for the purposes of participating in the Fixture Replacement Program - High Volume Users (HVU) Rebate including, without restrictions, all costs and all liabilities for any and all loss or damage, whether direct, special, consequential, indirect or of any other nature. For Internal Use ONLY Service Request Number 20 - Staff Initials

2 Page 2 - Washrooms Original - Toilets and Urinals Washroom Facilities - Pre retrofit Toilets total number of all toilets total number of 13L toilets total number of 20L toilets total number of 6L toilets Urinals total number of all urinals total number of 3.8L urinals total number of 5.7L urinals total number of 1.9L urinals Proposed Fixture Replacement Information - Toilets and Urinals Washroom Facilities Proposed Replacement Toilet - Option 1 Bowl Number Tank Number Proposed Replacement Toilets - Option 2 Bowl Number Tank Number Proposed Replacement Urinals

3 Page 3 - Kitchen/Cafeteria and Laundry Original - Spray Valves, Dishwashers & Washing Machines Spray Valve(s) total number of all spray valves total number of spray valves Volume of spray valve L or approximate age total number of spray valves Volume of spray valve L or approximate age Commercial Dishwasher(s) total number of all dishwashers total number of dishwashers Volume of dishwasher L or approximate age total number of dishwashers Volume of dishwasher L or approximate age Commercial Washing Machine(s) total number of all washing machines total number of top loading Volume of washer L or approximate age total number of front loading Volume of washer L or approximate age Proposed Fixture Replacement Information - Spray Valves, Dishwashers & Washing Machines Proposed Replacement Spray Valve(s) Proposed Replacement Dishwasher(s) Proposed Replacement Washing Machine(s)

4 COMPLETE AFTER RETROFIT Page 4 - Completed Retrofit Fixture Replacement Information Washroom Facilities Toilets total number of toilets replaced Rebate less than 6 L toilets total number of less than 6L single flush toilets $50 per toilet less than 6 L toilets total number of less than 6L dual flush toilets $50 per toilet Urinals total number of urinals replaced Rebate L urinals total number of 3.8L urinals $60 per urinal L urinals total number of 1.9L urinals $60 per urinal L urinals total number of waterless urinals $75 per urinal Spray Valves L spray valve total number of spray valves replaced total number of L spray valves installed Rebate Rate 50% of maximum $200 Dishwashers L dishwasher total number of dishwashers replaced total number of L dishwashers installed Rebate Rate 25% of maximum $1000 Washing Machines L washer L washer total number of washing machines replaced total number of commercial/top load washers installed total number of commercial/front loading washers installed Rebate Rate 25% of maximum $1000 Rebate Requested (copies of original receipts must be provided to process request) toilets at $50 per toilet = X $50.00 = $ urinals at $60 per urinal = X $60.00 = $ urinals at $75 per urinal (waterless) = X $75.00 = $ spray valves at 50% cost, to maximum of $200 total pre-tax spray valve cost X 50% = $ dishwasher at 25% cost, to maximum of $1000 total pre-tax dishwasher cost X 25% = $ washing machine at 25% cost, to maximum of $1000 total pre-tax washer cost X 25% = $ TOTAL $

5 Program Terms and Conditions Eligible Industrial, Commercial and Institutional Properties To be eligible for consideration under the HVU Rebate Program, a facility must: - be located in the City of Ottawa (City), and - be a high volume water user (i.e., consume 25,000 m 3 or more of water per annum), or - be a multi-residential property with 6 or more units. Page 5 - Terms/Conditions Conditions of Payment Payment of a rebate under the Program is conditional on: - proof of purchase of the replacement fixtures dated on or after the program start date, - completed installation of the replacement fixtures indicated on the application form, - Proof of Installation either through the provision of before and after photos or access for an inspection, at the discretion of City staff, and - proper disposal of the removed fixtures. Standard Rebates - Toilet rebates will be processed at a rate of $50 for City approved toilets. - Urinal rebates will be processed at a rate of $60 for 3.8L or less and $75 for waterless. - Water efficient dishwashers and front load washing machines will be rebated at a rate of 25% of the up to a maximum of $1,000 per unit. - Water efficient spray valves will be rebated at a rate 50% of the up to a maximum of $200 per unit. - All rebates will be processed to a collective maximum of $10,000. Selection of Participants - The Program does not apply to fixtures installed as a result of new construction or additions. - The Program is only available to HVU replacing high flow fixtures and equipment with low flow fixtures and equipment. - Replacement toilets must be selected from the City's approved listing. Application Deadline - The City reserves the right to extend or terminate the Program based on available funds. - Rebates will be issued on a first-come basis, based on the City's date and time stamp regarding receipt of applications. Applicant's Responsibility Each Applicant must assume all financial and all other responsibility for: - selecting an installer/plumber as required, - selecting and purchasing the replacement fixtures, - any preparatory or repair work that is required for the proper installation of the replacement fixtures, - proper disposal of all old fixtures, and - ensuring that the proper building/plumbing permit(s) as applicable are obtained. Provision of Information and Access to the City Each approved applicant must provide the City with: - access to water billing information, - if requested by the City, within a period of up to six (6) months from the date of receipt by the City of this Application form, access to verify installation and water efficiency. - The City shall be entitled to use any non-personal or non-identifying information, photographs and other data concerning a selected building in any report and/or promotional materials produced by and/or for the City.