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BACKWATER PREVENTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please usc lhis !nvoice Cost Breakdown as a lemplate for irnoices submitted as part of the Backwaler <br />� Prevention Device rebate program. [ither this form or your own invoi�:e torm with the foliowing lino items can <br />be submilted. This allows you io invoice your clienl according to your exisGng billing lemplate while allowing <br />city staH to identify how costs eligible for ihe Backwaler Prevention Device Rebate were accrued. <br />On/y labor and materials directly related to the installation and function of a baclnvater prevention <br />device are eliglble (or Ciry rebate and therefore should be incloded on the upper haff of tl�1s form. <br />Addifional costs may be added ro boftom of fhe form. � <br />�' tT'� � L v <br />E3usiness Name;�j�12�3���e5L cense Number. _QtS.�a_— <br />Business Mailing F,ddress: a�i�r� LGt (`I�VI _�l �—f-1%� r��n��`���'� <br />City State Zip <br />�' �111"�'�iL11J7CC(-Cst�� G��� e',.�)� f,�c� 2'! : C'c5Y�9 <br />Phone:�'c�.�� EmaiL•_ c �it_L <br />Fcos <br />Eiigible Tota <br />Othcr Cosls <br />Administratlon ! i <br />CCTV Inspeclior <br />gWV Instatl <br />Pipe replacemer <br />Surtacc restorati <br />Sile cleanup <br />Dovmspouls ! dr <br />Rar.kwaler vaWe <br />Hours <br />Per U <br />sewer pipe (up to 8 leeq _ reei <br />rted Backfill Yards <br />Cover (Irrigalion nox or <br />�o�e�� __ <br />b dem <br />� -- <br />not covered <br />ela) sum . �Ca— <br />aring Por Unil � <br />_� a= <br />Hour <br />-- — —� — ----- <br />--- Yarda - _---- <br />labar -- _--_- -- -- <br />--- -----�-- —r-�,—:__ <br />Cosls nol associaled with [3WD, and <br />nol eligible for rebate (delail belowL <br />Revisod 9/03/201d <br />=—�-- -- <br />$' <br />'Q.4 c <br />w(r _. <br />