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1 <br /> , i <br /> �� Backwater Prevention DevicE <br /> � Rebate� Program <br /> �-- <br /> For internal Use: F: ,�c; .t !J.,m:�� r <br /> Venr�or Payment Option Fc�rm � <br /> Please complete both sides of lhe form <br /> i <br /> Pro�;crty Owner 5ection (please print) <br /> _ �U�c�_ _ �, N ,� , <br /> Pm�;er;y rJe�er Nam� --- -- - _ - - - --- <br /> _ ,,r�� ���� _ .s�r_-__ _ - — — _ _ _ _ --- <br /> Pr7ueC; "+�t:1rr.,,. _:it✓ SI[ 1 <br /> � o !�{, <br /> --- �-����+ — — ---l�l'4 . _ U.� _��.%i(Jl__ _ <br /> A��C'^31F? Iv1Ei �I^Q l.,Cf�?55 �ily $1�fB Zlp <br /> - ---- -- - - _ _ .-_ I <br /> 'hu��e ��5-�i ��F%� Er�ad - - - - i � <br /> - - - �- • f - - -- - - - - -- - —- -- ' <br /> 1Fa P-oP�•tV ;)�.'ner, req�,esl to have Ihe C ty o� Fve�et' Rackw��e� Preventirn� Dev n <br /> �c�uala c�x�ck lor the mstallatio� ieteronced ��! the Property Addres: be made payah e � <br /> tn. ard sent to, the Vendor. By requesting the incenbvei�ebate check be maCe payable <br /> ;�� U�r, �,�r,rdor. I agree to the ����lowing' <br /> � I �ti�i�l ��ut rec�ivn a Back�vater Prrve��tinn Devicu iabale chc�ck directly trom U�,e � <br /> Cii�� i:` Gverett �, <br /> - ,����. r�niny payrn�rn� n' Ih� �arh�va:��i Prev��ribnn t)evicc rCb�ite to �ha V�r�:r� � <br /> �r�� ,, �r�� ,�.���n� � �•�r R��in R r�k�,;,il��:� I'ir:��rti���i D�v cc Rnt�a;e Pru'�Ynm <br /> ��•��.�nrn,,,.,,ts � � <br /> ' ;uiN��r :;� th�� �eii�;is�� ��( niy ri�t���trr !u 'ho Ver�lu� hsted on p�!7c t���q u' lh•s foim <br /> � .,u�i n�� ,inpinwil n( 4i�� cornpiotr 1 (l��:l��;�ntoi f'i��v�:iilum f)evicr� i�_b�i��� t���ck�u�n 1�'i <br /> tln� Cit� �;` t-dc�r�l <br /> -- _�t�;y=�f -- l�`.,- -- - - - _ __��'3 /f_ _ _ <br /> �,�-,,,ri;,,. �,r I'�ou�:ri}� n����,"�, ord�, <br /> I <br /> - � i <br /> ..-..'-r:.. �1.:'�r����'�1 .�lJ�� 1 ,' 2 ' <br />