|
i
<br /> 577R015 SCANU070 JPG
<br /> - �
<br /> �
<br /> ;. '.-..' ^. . . � . �. ... . .�. . ',� ..' �, '.: .`-":. i:. ' .. r'��' � !
<br /> Backwafer Fr.euentfon pevice Rebate'Program ` '
<br /> � Rebate ApplicaUon:Form i
<br /> I
<br /> -- I
<br /> � � �Property Owner Name ��✓Fi✓ ��I�GS(1[L�s.E�- ��` --- �
<br /> �.. � Installetion�Address � �� / 1--_I20��!�� ��-'— — :.
<br /> _ .. . - ,,9��,/ �
<br /> ' . .�Clly: .���"7I _ Statei-_���-_Zip_ � -- i
<br /> :. � -� . . .. ' .
<br /> 1 1 �,- I' �
<br /> iMallinaAddress(/diNrrenlC �f��_��/�/ ��e�4�L�dI� , - �
<br /> ' C'
<br /> � .Cltq:- .. "� 1/�'C.3�i.1 S ite.:` ��'�- ��P :.-'—(���� - '
<br /> .. . - - �..r �:� .-.,u,-: ' i
<br /> ��Email: _ _ _ phrne; 1��Q2_C��9. , I
<br /> ... � .�t " 5 � 1
<br /> =�Total Cost to Instell De�ire (Iro n rontrayfor mVo ce)�F * '-: �
<br /> t �_ -
<br /> ..
<br /> ._ . - £ — - - . . . j
<br /> �Pleaso vori(y lhe followinq, ��� . ��r �, %
<br /> . : . .. . ��' .�'�� ,-:. r �::5 , �: S � . i
<br /> � I-am the o�qner o(thr p�operiy�tihere Ihe ba�kwata�,��rc.v�ntion�devict�+is �nsWlled ! ; i
<br /> . ��� � ;...�.r �i .: .: � _ . ��. .�� �.
<br /> �. I v�orked wilh the contractorIo de ennine the ac�tion`or ie b3ek�tiaf r,pre��enl�on devl�e end � �
<br /> _ ��-�underslanA tlial'Ihe dec sion�raqarding.thn Iccatinn.ef the device,was muie. -I. �. ,--,. _ , - i
<br /> .�_ �' , :., ,.-., , 1 , �� - t i, � , ' ,
<br /> �
<br /> ��-Q_ ��4y W01�3Ctof�inSl�uC12d R1E hO�Y'U 8C6e55 It1SpBct,`e�d fn't�nt tin Iht d�vice;� ��:�'. v �:�� �
<br /> � ❑ 1 undersland that I im respon�ihle for hihmtamino lhe 6ack�r.�ler:•pievennon'tlevi ce and keepiny, _
<br /> - �.� It in good�vorkinoprAer,unless it is mstallcA'in the ctly ngh� c(.v;ay �
<br /> .�.
<br /> �� 161 sell my property I tivill�mak�p�tential-buveFs aware ol t�e b-�ckwatcr prevenhon �ewce a�d � ;
<br /> . : lhe necd4o inspecl 3nd maintain 1 on a regular basis . y:•� _ ;�,-� �
<br /> . '..,. . - . -- �. . i'•�' c . r
<br /> , [],�I am.encbsing�,all of Il�e-ii�c� u� G��-gn�ork.�i e�the yellow Rebal�Subr`nftal Chec4lisl)� _ � �
<br /> � �
<br /> Seleit(rom�lhe follawmg �� " � ;
<br /> r" ,
<br /> - ' ❑,The contractoi identdied dq��nspnuts or,o�hm drainag�Ilines lhal��e�e conrtected�lo my sPwer �, {
<br /> �line'(beRveCn niy house and th�il st211Cc1 pe,vic.,).and removi .1;'or reiout�d�lhem "� r ' �
<br /> � . � � 5' � ..... � • � �. -: `�. -,
<br /> �-�.To;my:kno�vledge m� prqr,'crty h is no�3ow npoutscr other drdin3ge conna�ol�d�o my scy er Ilne ��+ �
<br /> .. �(belween�iny howc and.�t�C�lnstalled.dcviu ) . �
<br /> []� Therc are detivnspou��,or,othu drair,iugc'Iw� cunnecl�d tu my:si.wcr line'(h�e�varn my-tiouse ; �a,, , �
<br /> � �� and the iestal!ed dewce):i,understand�tlialdcaving tluso ecnnectiunti r,rr,ates i r�sk-of.iliioding �
<br /> . - �..�and I accept thal nsk � 'C." '� .-.+.���. � ���, `
<br /> . � . ,„ . .,, '�,:•` . _ .
<br /> . . � . � .�.i �
<br /> �
<br /> t� . � 1�; :.f- i � ' ' i
<br /> . .. � t Y J : �.
<br /> ) 1
<br /> z _ � �:� � : �-1����s �
<br /> '' ��- Srgnafuie '"� • Date i �Y_J . �
<br /> � � r
<br /> � � r •
<br /> i �
<br /> > > �C
<br /> d- l � f z I, _ . : j
<br /> _ ia f
<br /> � ' ]i � � � 3:� i
<br /> � I
<br /> + ,
<br /> ` . . . . . :�d�� � . .:. . r.. . . . . . • �-. . .
<br /> ' . . .... . . . . . . . . �
<br /> h;tpsl�mailgouglecoM �srs/mail-staUUJs/lpgrtuil.nvinen.TPd119zpPpBU.01�m i,1,IVa�PiMaYE7G_JGI.IN11�1'VP:Ld_�7JUI4d i9REngG5nAP5u9.8. . 111
<br />
|