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� Backwater Prevention �evice Rebate Program <br /> , Vendor Payment Option Form <br /> Pro;ect humher (Gf/fo Piowde; <br /> Plcase complele both sides of thr, forrn <br /> Property Owner Section: <br /> i -- — ---- — — -- --- i <br /> � Prop^rty Ovrner Nam^�. �--�'`�'<-�v �wl_� ��--�"�'' <br /> I, in;!allalion Address� �C-'\`� �'`��-`�� ��' i <br /> ! C�ry.�.1,�.,�'a State`�.:;p_. Zip�. e:��(2.JJ\ . i <br /> i <br /> ��i ;;r�;'.ing Atldress(d dJlerenlJ. — <br /> City �i 51ate- Z'P� '', <br /> ' .Ci� 'L�-+t� �,��� � , <br /> Finair.�c,ve.., . 1•�tayc-�w.- � .-����. Phone (�{l�) i <br /> Tmai Cos�m ins�ail Device(�rom comracrorinvo�ce)�5��_Y'�� � <br /> I <br /> I the properry owner.requesl to havr.Ihe City ot Evereit Bachr:aier Preventien Device iebale cP•ecA <br /> for the inslal'alion ol lhe deaice al the ahove refarenceU propc�ty�ddress 5e made payable to,antl <br /> sent to,lhc ventlor spetiBed on Ihe ba[k ol lhis(oim By reque5ling Ihe iebate Chet.:be madc <br /> paya6!e lo the vendor.I ag�ee lo Ihe(olln��ving�. <br /> t I wili not�ecerve a rebale check d�rectiy Imm Ihe City ol'rvrre�t <br /> 2 Assigning paymenl of Ihv rebale to Ihe vendor d�es not c.crnpt mc Imm Gickvnter <br /> Prevontion Devicc Rebate Piagmm requiiomcnls. <br /> I aulhonzo ihe release o1 my rebate to the vendor hsted on Ihe hack ol this lorm pending I <br /> approval of the completed Hachvater Piev.�uon Device rebale packet by Ihr.f,Ty of Evemtl . <br /> I <br /> I '__. <br /> . . � j: ��- 1��-- / - Z 3 -� �_ <br /> i —��`-��_ <br /> ! patn <br /> � 5ignalwe of Piope�ty Ov:nei <br /> L __. _____.__ __ __ ___ __. ._ ._ _ __ __. _ __ ..._ . . _ <br /> _. _ _ � <br />