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- - - - ----- -_ _- - - -- - -- -. .. . ._. <br /> � _ . � <br /> � Backwater Prevention Device Rebate Pr�gram <br /> Rebate Application Form <br /> r - <br /> Property 0wner N:�rno _J��11C��----��_Si.f.rl.�'� —__ _ ___— I <br /> Inslal�ation Address �C,b7 C�Jj�_���(,,,'� ___ <br /> c:�c _�Ve.('c�� s����� LL� c� ��"'nl <br /> y -- - - fl-.- �'----� - - - <br /> i <br /> latadmy Address (d dillcicnf) _ __ _ <br /> Gty _ Stala _ —L�P - -- — ------ — <br /> Finail� _ _ __ _ Ph�ne� ( ; _ �� <br /> � Total ('osi to tnstal� Dewce Ilrom contracfor urvnirc�!� 5 c�'y S�o ��� ___ _ <br /> � -� ----.__- -- - --- - � <br /> Please verify the following: <br /> � I am Ihe ov;ncr of Ihc F,ropor�y whure Ine ba�kr:�tcr prcvent�on dev�ce tivas mstalled <br /> � � I worked vnih the coMraGtor to de�ermine Ihe locabon for the bar.kwaler p�evr.nUon dc�vn�.r and <br /> ndersland that the Aec�s�on re.ga�Amg the Inr,afion of thr dnnr.? was mine <br /> �r�4y cuntractor inslrucled me ho�v to access, inspec�. and mamlain Ihe dewce <br /> 1\ <br /> ��I understand lhat I am responsible for maintairuny the b�cka�ater prr.venLon dewce and kerping <br /> i <br /> � t in gnoA�vorking �rdcr, unlrss il is installeA in thc aty nght-o(�w,�y <br /> �f I sell nry pruperty, I �vill make polenLal huyers aware of the backw;der preverd�on device nr�d <br /> / he necd to inspect and maintain il on a regular basis <br /> 'ti[ I :m� rndnt;inq all ol the ne:i�ssdry pa!`env�nk lu:.e lhi� yellow R��h;d�� Submq�al l:h��cklistl <br /> >> <br /> Sclect Irom lhc following: <br /> � I ho�.�mlidi.lur ideidihed d�wnsp�wl� ui o�her dr,w�.agr qin� •, thal tvrm r�.nnnec�r•d �n rny Sermi <br /> linc�beN:cen my house ai�d Ihc �n;talled dewce) and removed, or reiouted Uu:m <br /> �Q To rny knuwledge. nry piopeity has no downspouts ui oUier drainaye connerted to my s��.vei hne <br /> �l�Q�etween rny house .ind Ihe insl�dled device). <br /> � 1 Thcrc arr. qownspou�s ur olhcr Aramage lines connected to my sewer line @etweun my huuso <br /> ,ifl(�Illp. IIISIAIIP,(� APVIf.P) I unArrstand ihal leawng Ihese conner,hons creates a nsk nl(loodmq <br /> ;in�i I acr,rpt ihat m,k <br /> �f� J � � <br /> SiynatureJ 1��' � _�(�l���Dafe _�- I 7 " [l� <br /> T� � <br />