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Hackwater Prevention Device Rebate Program . <br /> Rebate Application Fonr� <br /> PropertyOwnerName: Jom� r�e_ 1� • Fuso <br /> IrrotallallomAddrea: IS 12 Bc�+r 11v4. <br /> cny:,_ Eu+�efdr s�a�: w.� z�P: 96w1 <br /> Meiling Address(il dMslsnt): �O IS'1 <br /> c��y: Fw�ealle- s��a: W1� z+P: 96ut� <br /> Emeil: �w��v►�p���v�oG(. ce.v� Phone:('f�S) ZS Z - I B.�k'7 _ <br /> Tdal Cosl to Install.Device.(Iiwn conhactor Imroke): S 2�!�.0�' <br /> Mww w►Hy tM�oMowino: <br /> � t am the ownsr ol lhs propeAy whero the backwater preveMfon'dwke waa Inshllsd. <br /> � I waked with the oonV�ctor to determine ths�locatbn fa the'beckwater provendon dsvios and ' <br /> undentand thal the Aedsion repard(np Ms bcaGon ot the device was mine. <br /> � My contrador InebueSed me how W acos�s,inspect,and mafnteln Iha dsvice. <br /> '�I ix�derttend lhet I am:n�ponsible(or malntelnirp Ms br�ckw�ter prevenUon devta and kespNp <br /> R in good worWnp order,unkss N Is Installed in tM city�iphRof-way. <br /> � H I seq mY ProP�Y�1 wiN mMce poantiN tiuyxs aw�re of d�s Wdcwater•provmdon dwice end <br /> Ihe�nesd to insped and m�NMsin It on s npular beN�. <br /> � 1 am encbsing all of the necestery papervvak(uae lM yellow Rebate Submlltsl Checklisl). <br /> B�Net/rom tM fallowNq: <br /> � The contractor id�ntlfied dowmpouh or atMr droinepe Nk►es lhat were conn�cted to my seMwr <br /> Nne(b�Mreen m�•house and the inetelbd devioe)end removed,or rorout�d them: <br /> pTo my knoMAadpe,my propeAy,has no downspoWa or other dralnape connectad to my sewer,lina <br /> (belween my haise and Mis fnsUlbd dsvbe). <br /> �1 Thx�an dowmpoub or�other drainege IM�s conn�cted to my eewer Nne(b�N�een my hou�a <br /> ( end the fnstall�d•device),I underatend thatJeavinpdhess connedkms croetea�a rbk Mtlood(np <br /> ad I eccept lhN rbk: <br /> 3/pNwn I�M1�UuQ� IX:, � ate��l'E- <br />