Commercial Aerator Replacement Program Request Form

Facility name:

Facility Address

City/Town

Province

Postal Code

Contact First Name

Contact Last Name

Contact Phone Number

Contact Email

Number of handwashing faucets at facility (if known):

Please indicate any details about your preferred date and time:

Water Bill Account Number (if known):

Personal information contained on this form is collected under the authority of the Local Government Act and is subject to the Freedom of Information and Protection of Privacy Act. The personal information will be used for purposes directly associated with this project. Inquiries about the collection or use of information in this form can be directed to Glenn Harris, Senior Manager, Environmental Protection, Capital Regional District 250.360.3090.

Commercial Aerator Replacement Program Request Form

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Territorial Acknowledgement