Residential Refrigerator Recycling
Rebate Application Form
Name on Utility Account Account #
Zip Code Address Phone
Mailing Address (If different) Zip Code
Customer Information
Item / Appliance Make Complete Model #Date Recycled
I certify that I am the owner(s) or tenant(s) of the real property where the appliance(s) was removed, and that the foregoing information is true and correct. I also certify that the appliance(s) is operable
and that it was recycled by a certified recycler. I further agree to indemnify and hold harmless the City of Riverside, its officers, employees, and agents from any damages related to my use of this
program.
Signature of Applicant __________________________________ Date __________
Signature of Owner _____________________________________ Date
_________
(If Applicant is renter or tenant)
Recycler (you must include proof of recycling)
FOR OFFICE USE ONLY
Certication of Delivery Approved for Payment Approved for Payment
Signature Date Department Head Date Finance Department Date
RPU Inspector Information:
Date Inspected ______________ By __________________________ Notes __________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
JL Key 6020109080 Object 456200 Rebate Amount
Use the form below to fill in your account information and information about the rebate program you are applying for.
Once you've completed the form, PRINT THE FORM, SIGN IT, and submit it with proof of recycling to:
Riverside Public Utilities - Programs & Services - 3025 Madison St. Riverside, CA 92504
Failure to provide complete customer information, signature(s), model numbers, or receipt copies may result in processing delays.
Please allow 4-6 weeks for processing. Rebates will appear as a credit on your RPU billing statement.
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