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2. ACWD provides complimentary toilet leak detection dye tablets and toilet flappers

   Provide information requested to receive FREE toilet leak detection dye tablets, a toilet flapper, information about finding and fixing leaks around the house and accessing the My Smart Water Connect AMI customer portal, and the California Water Efficiency Partnership's Practical Plumbing Handbook.

4. Please provide complete contact information.

   Kits will be delivered within 10 business days. Please call ACWD's Water Use Efficiency Team at (510) 668-4218, if you have questions.

6. ACWD Water Account Number (if known)
7. Phone*
9. Reply Email Address
   Enter the email address you would like us to reply to.
11. First Name*
12. Last Name*
14. Street Number*
    Mailing address
15. Street Name*
16. Street Type
17. Apt #
19. City*

    1. Fremont
    2. Newark
    3. Union City

    You must be a resident of one of these communities to receive these items.
20. Zip*
21. Mailing Address (if different from service address above)
23. I live in a Homeowners Association*

    1. yes

    1. no
24. Homeowner Association's Name
    If you live in a Homeowners Association Community, please provide the name of the HOA above.
28. Number of toilets in your home:*
29. Age of Home*
    -- Select One --Built prior to 1980Built between 1980-1994Built after 1994

    Please provide information about the age of your home.
30. Have you replaced your toilets within the last 25 years?*

    1. Yes
    2. No
31. What year did you replace your toilets?*
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field