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Department of Water Safety High Efficiency Fixture Form

2. First Name*

3. Last Name*

5. Address*

7. City*

8. State*

9. Zip Code*

11. How do you water your yard / property?

    1. Do Not Water the Yard
    2. Drip Irrigation
    3. Hand Watering
    4. Spray Irrigation
    5. Other

12. If other, please specify

14. Would you like Maui County residents to learn more about any of these water technologies and issues?*

    1. Greywater
    2. Rainwater Catchment
    3. Source Protection
    4. Water Conservation
    5. None

18. Fixtures Given*

    1. Bathroom Faucet Aerator
    2. Kitchen Faucet Aerator
    3. Self-Closing Hose Nozzle
    4. Shower Head
    5. Toilet Tank Bag

    Department of Water Safety (DWS) Employees: This section is filled out by the DWS employee.

Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field