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�;"���� Backwater Prevention Device Rebate Program <br /> "'�`v�n Vendor Payn•ent �ption Form <br /> �� ,.,�, ,, .,,,,�- ,� ,., ,,, ��.�•:;:o, <br /> Plcase complete hoth sides of the form <br /> Property Owner Section: <br /> _ _ _ - <br /> I�r,�pert ' C�5'�erNarnP - �� :���' `� . <br /> r _-=��il"�_:�l :�t �_��_�:L.:.-_ _ - - --- <br /> I•�;'a'�I�t�onAdArnq¢� _A,����;� �Lj_ �l.l_�__���- __ � <br /> ( t i,/ "�/ <br /> ('uy /--. �y��t�.�l. —_ SI[de 1�)F� T.�p (-�l'J��i'� �f�i'�!\ i�' � <br /> I,SAdingA�(1'PSS �r(f/i//PlPlll,) 1�n1����� ��� ���1_���_�.1� _ <br /> City. L�\�`3 1 3_LStL�ISL Slate . ��!-� ----�Zip��1.- L.�-- -- -- <br /> ; <br /> �,�,��� �L��i f 1�,I��c����- Y,�'L1�� „��,�ho�e ����_�'z:�t ���L��`� <br /> To:;i�C,.,.t b� ircta�i UPvice lhom conlrattorm✓our) $_ — �� <br /> i ^� ;�r�,��-ty,-��:n�.;, �Nques' to h.we t1m C�ty ul tveieC [3ackr�aler f'revenlion D�vice rebati�c�rc� <br /> ���� r��� �����•ai:�;�� �� ��t u��� tlev�ce at Ine ahove relerenceC pioperly ad�ress ho madn payah�e t�, .ird <br /> �+.r,t t�,7�,e vend�.�r sp�-�.,l,ed o�Ihe bacP o1 Ih�s brm By�equest-'�g ihe rebate c§eck b�n,are <br /> �:i;.�hlu tu lhr vendor. I apreC lo Il�u lullow�rg <br /> 1 I�.� n�l recurve a ieDtde[hec�dnecUy hum lhe Ctly ot Evr.�'t <br /> i 4•s�.yuiny payii�enl nl the rebale In tne vendor Aoes no!e.rmpl �ir Ircm f3nc�v.ab�r <br /> I��rven�inn Dev�ce Rrba!r�'inurun requremr�tr. <br /> I .- _ _._.—__ . I , <br /> I I ��un�u���e Ihe re�e.+se of�ny ieLate lo Ihe vendor hs;cd uu 0 r h�.ii.�• c�f!niti lunu pr•ndmy I <br /> '� approval nl Ihe r,omplelcA Radwatrr Prevenlion Device iebate partPt hy Ihe l>ty nl f:veretl �, <br /> " � � , I <br /> i `�/, ' � ,`•' l <br /> I / / \^_ L � " s. _ _ . I_ l:1 i)l -I-,.,i I <br /> � 1 <br /> � ��<—.j.- _ .- ___—__— _ <br /> I I <br /> S:qnalwr•ol Proprrty O�vn�r U:IIe <br /> I <br />