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; <br /> I <br /> i <br /> � <br /> i <br /> i � gackwater P�evention Device Rebate Program <br /> R� oate Application Form <br /> � ----�— � —` I <br /> ��i Propert/L4rner Nume �IJ/%/91. iJ -r lJ![��'S1C / "�x�s � <br /> �I In�pl�a;nn hdA�c:s��_ _rCO�r� � <br /> � 9R 2oi <br /> I Ciry:� •J[ � �� Stalc. Lp <br /> � Mai5npAdtlms5l��Q,r/oNnp. --_. � <br /> I �yy SI1a Z�p . <br /> � ErtuN: _ .� 1 �}���Yr"IiR1 Fh�ne ( 1 ��i•ZJ��s'� � <br /> T�1�t Lus�t�Ins'�9 Den:e(llom conhscior mra�co7:=__ __._ i <br /> � _----_—'_._______— —_..- J , <br /> Please vorlfy tna follow�ing: <br /> �j I am II'�e avnCrol I]e prcpelty w�e�e I�C backwa;n�prtivo^tion decke wm�n51a7a1 .. <br /> I [; I w�r%e�vnN 11w+centrnclw to delnnn:no u:e�owiiw In Ine hucM.e;ar prr,er.l!cn aevlcu anC , <br /> un]ci.hntl ina:tlie Cedslon regarmn9 ihe batWn oi Uw devico was mins. <br /> ' Q t.1y con:rac�or I�sttv:tod me how lo n:.sss,Innped,end mairtnin Ihe dev�e. � <br /> n I un�rstand ih.:I am respMs'ule lor nuintayn9 t��e EaUwa!e�yr+er.Uon do��a�'4 ko:D���O <br /> it in{pod v.vrkhg order.unle59 it 151ns1a�ed in IAc tMy iighFolivay. ' <br /> I ❑ II I ee9 my proy_m/,I will m9te po:cn!lal birycM1a av+am o���c Da;kvm'er pravenFon dxvice nn0 <br /> lhe noed to!nspect nnd mdnm!n ii on e m9ular oes:s. <br /> � I nm enda�lrry�a��ol IAc n_ce:sary WDe�+�xM(uco tha vutlo-n Rebale SuCml!�al CMad.irst). <br /> Svleet hom�he folio�.tng: � <br /> ❑ itm a.�iroucr WnntiOed dovmspcu�s or ofht:r Om:mOc ihnes Ihat�rete tonnecle�I�my cewer . <br /> � Imc�DrM�ecn my housc ond Ihe msln"ed Cm�icn)�nd�en�o�W.a mrculotl t�em , <br /> ' Q To my knawhdyu.my p:eperty h.s no tl�+wnspouL•or oNer tl�u-na90 connrelM io nry e�ewer 6rw � <br /> (Uy�.vrnn my twu5o�iM Inn instclk0 de•.+ce) ' <br /> ��crc orc Cawn5Wu�5 0�0'Scr dr��n,!90 I�nas tonn�atea ta my rrwwr linn(Cc�wocn my huuse � <br /> anJ l�w�nhlAlh.d de��lCc!.I an�en:Ona Indllydrng IheSe o�Mtt1k'n.trpaltlb P rltik n7lboEmq <br /> ana I accepl If1,l rist � <br /> s�onaruro, �J/ �/��axm��_ � <br /> I <br />