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Backwater Prevention Device Rebat� Prog�am <br /> Vendor Payment Option Form <br /> ProJect Number: .(Cify to Provlde) <br /> Pl�as�compleb both sides of the form <br /> Prop�rty OwnK S�ctlon: <br /> Propeny Owiwr Name:_,1 J n� l4. F0.9S a <br /> ImtaNadon addnse: 1 S(2 Sa.kac ��e. <br /> Clty: ��'� Sute: ��R Lp: 49201 <br /> MeNinp Addrots(MdNh►wrt): QO l S''1 <br /> ciy: �w.�k scaa: l,JJ1 z�: 98 � <br /> Em80:_�wtini�•Cm�wL;(.Cew� PhoM:C1tS� 2S Z- 1�4�7 <br /> Total Cost to InslNl Oovia(Irom confr�ctorinwky):i « 2�l O . 0�{ <br /> I�ths propetty owner.roQuest to heve ths C(ty of Ever�q BadcwaMr Pnvendon Devios rob�le cMc�c <br /> ro►a»�.w�o�aa�.asr�a n,.,eore�.h►.nad aavnr•aa�e..n.�wa.wraew�o,a„d <br /> wnl W�Ihe wndor�p�cified on ths b�ck W Mh brtn.BY►�4u�+►inp Ms nbeE�check b�m�de <br /> WY�Ws b the vendor,l aproe to the toNowkip: <br /> 1. �wiu na roanre a rsbete ctMcic dkedly hom au c�ty or EvsroB. <br /> 2. Melpnl�B WY�t of the robN�lo the venda doss not ex�mpt ms from Badcwater <br /> ProveMion Devios Rebele Propram roquirertbr�te. <br /> I aulhaizs tM roksw oi my robate lo the vendo►Iisted on the bedc ot lhfa form pendkip <br /> approval oi Mis completed B�ekwater Prevention Device rebate packet by ths City of Ewnit <br /> 4�. �.- � -�c.�zsl�� <br /> Slgnaturo ol Propsrly Owner Dafs <br />