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I ORIGINAL BAY AREA WATER SUPPLY AND CONSERVATION AGENCY APPLICATION TO P ARTICIP A TE IN HIGH EFFICIENCY CLOTHES WASHER REBATE PROGRAM FOR FY 2004-05 The Bay Area Water Supply and Conservation Agency (BA WSCA) will be contracting with the Electric & Gas Industries Association (EGlA), a nonprofit corporation, to administer a program of rebates to purchasers of high efficiency clothes washers which use less water, and consume less energy, than conventional models. Participation in this EGIA administered program provides BA WSCA members access to state grant matching rebate funds for this program in addition to access to a cost-effective way to offer their customers an incentive, via rebates, to purchase water conserving appliances. Members which want to participate in the program for FY 2004-05 should complete this application and return it to BA WSCA, attention Nicole Sandkulla, no later than June 28. 2004. 1. NAME OF AGENCY Ct '1 of Q.; 1) \,.)COO c.. \ 't"'" 2. ADDRESS: \ "'\. ÐC> %(to-..Ov.t; o..OUOO <;) ~\,..., \ U o¡, '1.0 <.1 , 3. CONTACT PERSON: '"' ~ \.)~~ ~SJ\) 4. PHONE: ((,,\- 0) , ~() -14.~ 'ð 5. FAX: ( to S'b) ., ~O -, L1 '1. \" 6. E-MAIL: n~\ ~~~OCOC-\~ .()~l. 7. LEVEL I REBATE PER CUSTOMER (Agency Share):$ 7 S.- 8. LEVEL 2 REBATE PER CUSTOMER (Agency Share ):$ ,1..5'. - 9. BUDGET FOR REBATES FOR TWELEVE MONTHS (JULY 1, 2004 THROUGH JUNE 30, 2005) : $ '-, ern (- , Participating agencies are responsible for EGIA's costs for implementing the program and associated BA WSCA staff time in addition to the maximum rebate budget authorized in Item #8. These costs are: A. Other identified expenses including printing expenses (estimated at $3,500). This will be allocated pro rata among BA WSCA members electing to participate, based on their respective maximum number of rebates to be paid. B. A monthly administrative fee of$850.00 (a total of $9,600 for 12 months). This will be allocated pro rata among BA WSCA members electing to participate, based on their respective maximum number of rebates to be paid. C. A charge from EGIA of$6.25 per rebate application processed plus postage. These will be tabulated monthly. Each agency is responsible only for the approved and denied rebate applications submitted by its customers. D. An estimated charge for associated BA WSCA staff time of$5.27 per rebate application processed. By submitting this application, the agency agrees to pay its share of these charges within 10 days of its receipt of an invoice from BA WSCA and to advance funds sufficient to cover rebate payments, up to the authorized budget in Item #8. The agency agrees to pay its percentage share of other reasonable and necessary expenses of the program that may arise over the period of the program provided that these expenses are agreed to and approved by the participating utilities. The agency also agrees to promptly respond to BA WSCA requests to confirm customer status of rebate applications from its service area 0 opera with BA W A generally in administering the program. Date: l/i rtYt Ed ~ ver~tt . Name: [Please print] T T' T -.