528-FLOW
Customer Information
Just take a few minutes to highlight this form, next copy it (ctrl-c) to your clipboard, then paste it (ctrl-v) into an email or Word document. After you fill it out send it to:
528flow@charter.net
Call 805-235-0873 or 805-235-5814 with any questions.
Customer Name __________________________________________________________
Retrofit Address__________________________________ , Los Osos, CA
Mailing Address __________________________________, State ______ Zip __________
Telephone Number ________________________
Email Address __________________________________
How many bedrooms? ____ How many bathrooms? ____
Are you interested in purchasing a third or fourth bathroom package/s? __ Yes or __ No
Estimated age of home? ____ How many occupants of the home? ____
Do you currently have a hot water recalculating pump? __ Yes or __ No
Do you know the gallons/minute rating of current bathroom fixtures? toilet ___, faucet ___, showerhead ___ _______________________________________________________________
Are you Homeowner or Tenant? ____________________________________________________
Any special water uses?_____________ Any special plumbing fixtures? ______________
Typical miscellaneous parts including water supply lines and angle stops are included as needed.
Addional Charges: ADA compliant toilets (comfort height of 16”) charge is $50.00 per toilet.
Please be aware there is a $25.00 per toilet disposal fee.
Do you have a lawn? __ Yes or __ No Would you consider replacing it? __ Yes or __ No
Are you aware of any water leaks inside or outside your home? __ Yes or __ No
Thanks for completing this information form! We’re looking forward to saving water with you,
Your friends at 528-FLOW
www.lo528flow.com
