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_ � <br /> I _ .. ., . .,,,., No. 1329 P. 6 , <br /> Backwater Preventlon Devicg Rebate Program <br /> Rebate ApplicaEion Form <br /> r�-,�� �� �M ; <br /> Prop�xty Owner Neme:�Lc�.r�.�F � �1 � C`�rL.(��ru <br /> insfallation Addrece:_�S (.�{ (�p �!p �.U Q, ' <br /> c�ry:_ �vp-('e� siaia: A ,�z1p. �l � Zo 1 , <br /> MailinpAdtlrosa(lfdiHe�nU;�/ZL I�,e.cl�er � ,�¢V� �(J� <br /> ��: �l�c,�-rn� S�:__��_g__�P;' �( $�12 2 ' <br /> � <br /> EmaiL• �D P0� �2���ehfc+Ip� ce�-n Pnone:��45Z -7�d / I <br /> Tolel Cost to Install Davice(/rom conhgttor MvoioeJ:i��I ��• ,5� � <br /> I <br /> Plea�e verlry fhe follawlnd: j <br /> i <br /> � I em ihe owner oT I�e propeAy wharo the beckwater prevaMion de�iice was instalied, � <br /> � I worked wtth the eonVactor m determpb Ne IxaUon for the bacMvaler prevantion devlce and I <br /> understend 1h91 ihe deolelon rega�ding tAe loceqon of q�e dev;oa wcs mine. <br /> ; <br /> � My conheUor(netrudod me how to aoce�e, (napeq, and mainhaln the dEvbe. ! <br /> (� I understand that I em r�sponsiDb for mainteining the backwater preya,�tlon dsvios and keepinp ! <br /> it in pood working order,unlees it is inWatled in fhe elry ripht-0l-way, <br /> � If I sell my property, i wlll meke potenfial Duyers eware o/the backwafer preven�lo�as�►ce and I <br /> the neod lo Inspect and maintain Y on e regular baele, �. <br /> � I am ene�oeinp all ot Me neooteary peperwork(use the yellow Rebate Submilbl ChecMiet). � <br /> SNed trom the foNowinp; � <br /> � The co^lrecto�Itlentified downapouls or ol�er dralnape Ilinea thut wem conneded to my sewer ' <br /> line(bchveen my houne end Ihe Inetalled device)end rertwved,or rerou(ed tham. <br /> � To nry knowledpe,my prop�rty has no downapouts w other drt,lnage connected to my sewer Ilne ' <br /> (berveen my hou8e end Ure ingteRed devioe). � <br /> ❑ there e�a da�vnspouts or other dreinepe lines conneeted to my eewer line(be(ween rtry haee <br /> end the in'smlled deviCa), i understend Nat leavinp these contia:lions cneates e�Vak at flooding <br /> end I axept thet dek. � <br /> � <br /> I <br /> S�f►RE11►9 �YlB V1�x'O ' ^-+ �� <br /> _-- i <br />