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2. Please Note: All information must be provided.
4. First Name:*
5. Last Name:*
6. Preferred Name:
8. Address1:*
10. City:*
11. State:*
12. Zip:*
14. Phone Number:*
    Example: (xxx) xxx-xxxx
15. Alternate Phone Number:
    Example: (xxx) xxx-xxxx
16. Email Address:*
18. Account Number:*
    *Your account number can be found on your water bill or by calling (909) 364-2660.
19. Approximate Lot Square Footage:*
    *Must be less than 10,900 square feet
21. Pre-qualification Questions:
23. Do you acknowledge that this program requires you to purchase the Flume device for $40.*

    1. Yes, I acknowledge
    2. No, I decline
    3. I would like more information

    *The Flume device retails for $199 and is offered at major discount through this program.
    For more information, email the jloukeh@chinohills.org or call 909-364-2804.
24. How did you hear about this program?*

    1. City Brochure/Recreation Guide
    2. City Letter
    3. Family/Friend/Neighbor
    4. Social Media
    5. Other
26. Property Owner Age Range:*

    1. 21-31
    2. 32-42
    3. 43-53
    4. 54-64
    5. 65+
27. Are you the homeowner or tenant*

    1. Homeowner
    2. Tenant

    *Tenants may apply, but only with the permission of the property owner. Contact information for both parties MUST BE listed on the application.
29. Additional Comments:
    *Please provide any information that we should know about the property.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field