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� Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Pi�perty Uwner Name: Q!Nlc,�t �YL�i � ti��_Fh �CT _ <br />Installation Address: y `�n � �'/ � r':a �1�L <br />r�,�� 1.>Ja z� "� 2 o i <br />Cdy� __ C� LZi-_I-{- Stale: p:_L <br />Ivtailing Address (ilddleren�): � V G l � �• ��' _�"�� _� <br />/� /� �7 � <br />City: �(� 3��C --- State'._ �J�_Lp. "l7� �_�/'L� <br />[mad' �. � )C '� c ��-'✓ C��' �� ('� � DY�_ Phone: (LCE 1 �� - �yy,� <br />lbtal Co�t to Inslall Device (Irom confrdcforinvoiceJ: S__�.,f� �� <br />Pleasc verify the (ollowing: <br />ti�.]'I �m the ovmer of Ihe property wherz Ihe batktvaler prevention device v:as installed. <br />i <br />�i I �vorked v�ith Uie contractor to delermine the location for �he backtvater prevenhon device and <br />undersland Ihat the deasinn regarding the Incalion of Ihe dewce was rnine. <br />� hty conlraclor inslructed me how lo access, inspect, and maintain lhe devlce. <br />`[�] I undersland Ihal I am responsible for maintaicing the backs�ater preven6on dewce and keeping <br />� il m yood woiking order, unless d is insl2lled m the city nght•of-�vay. <br />�] II I sell my prnperty. I vrill make potential 6uyers a�vare of �re backwater p�evenl�on device and <br />� the nced to inspect and mainlain it on a regular basls. <br />�1 I ain endosiny all of the aecessary papen•�ork (use tne yellow Reba�e Submiltal Checklisl). <br />Select trom Ihe tullowing: <br />( � The contrador identified Anwnspouts or olhzr diamage Ilines that were connecled lo my sewer <br />tine (bebveen my house and the inslailed device) and removed, or reroute7 them. <br />(] To my kno�vledge, rry property has no downspouls or other dramage conneded to my sewer Gne <br />(betu�een my house and Ihe inslalled device). <br />i <br />�Q There :ue downspouls or olher dreinage Ilnes connected lo my sr.wer line (heM1t�een my house <br />' and lhe inslalled device). I undr.rstand Iha� Ieaving Ihese conneGions creales a risk of Ilooding <br />and I ar.cr.pt Ihal risk. ' <br />r� <br />Signafure^l--'---��� Date +/2l/�'y <br />�/ <br />