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�}r gackwater Prevention Device Rebate Program <br /> �r�� �� Rebate Applicatio� Form <br /> C��"� <br /> PropertV����e�Namo�_. _tif�S6y_.�'(.�LU� <br /> � <br /> Insallalian Adtlress: �� � �— <br /> Gry..-1r���� Slao:��21G� ��� <br /> �1di11�9 AddIB65�d diKerenU:_�_].L�—�� ___ <br /> CiN��_ / �p'—- q � �J <br /> Emad� i tX CV���, (StateL•Z+..i�d.ys'Pl�ane: � )��'�� ' / 7� /: <br /> i <br /> ITaial Cost lo Inr,Y.hllOev�ce(�n:m conf2cicrl.,:�cicn):5 ��f�/ <br /> L <br /> Please vcrify lho lallowing: <br /> A[lllam the otivner of Ihe propertY�'+hero fhe bachwalr.r prevunllon device was�nstelle�. <br /> ��� <br /> 1 }n.m�vorkod wilh thn conlracmr to detertnino�Ihe location lor Ihe haciwaler preventlon device and <br /> ! �ndarstantl Nn tho aeclslon rngaiAine,t�e bca6on ol tha device x�as mine. <br /> � �ty contractor Inshucled mu how,lo accexs,inspacl,and maint:n Ino Cevice. <br /> � <br /> �understand ihat I am responsih�e for maintainin9 the�acAivater preventlon tlevlce and keo0��8 <br /> il in gooA��io�kinp nrCet,unless It Is Inslallotl in Ihe dry rigA4obv�ay. <br /> �I sxll r..y D�ope�ty.��+�iii:nake potenlial bayers av:are ol l.'.e Oackwaler preoenllon device eno <br /> �(�n neatl to InsOoot xnd malntaln it on a regular 6asls. <br /> /S�am onclosing all uf Ihe necessary papenvad(use Ihe yellow ReOate Su6m�tlal Chec4llsq. <br /> Sulec�from Oic(ollowing: <br /> ❑ The conUactar ICenUGed tlm•+nspoms or olher drartia9e Ilines�hal erera cannecte0lo my se�ver <br /> line(betwoen my�ouso anE lhe Instal;od aovtce)and remwed,or raremeG them. <br /> ,%f�yr�,-7o my Anm•:Iedge,my propedy hos no Go�.vnspouls or ot�er Gralnaga connoctatl�o my snwer Ilne <br /> ' ^ (6eGseon my�ouse and lho installeC dnolce). <br /> U LIIhere arr downspcu�s cr ather dralwge Lnes connectetl ta my soro�ilne(botween my house <br /> anJ Ihe histalled Devica).I undarStanG Ina�leavirg Ihesu connuctlDnS croales a nsk o111aoding <br /> a�d I aGCLpt lhal n5k. <br /> � <br /> . � r /� // <br /> Signatu�e' �i •' �Onte�� <br />