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��, <br /> � Backwa�ter Prevention Device <br /> ,, <br /> £�� , F;ebate �rogram <br /> For internai Usc: Prcjecl t:�mber _ _ <br /> Vendor Pa�mE� : �Jption FUrm <br /> Please complete both sides of the form <br /> Property O�vner Section (please print): <br /> Tio nn i i�i C,o �� � G��n�� �ct�c� - ----- --- ----1 <br /> Prooerty Owner N2me _- I <br /> reo�_L��LL��=--�v�rCc�r� �,v� �i3�.o � _ <br /> Froperty Address City State 7_ip <br /> � Alternate ���ailing Address City State Zip <br /> � — -------- -- <br /> � Phone t��S- �S�- ,S�S�D Finail � <br /> I. ;I•e Property Owner, request to f��ave the Cily of Everett Back�a�ater Prevenlion Device <br /> i��b��te check for the installation re(erenced at the Property Adaress be made payable <br /> b�, and ;ent to, the \/endor. By requesling the incenlivehe,�ate check be made payable <br /> tc� thi: Vendor, I agree to the (ollowing: <br /> i I �vill nol receive a Backw�ter Prr_vention Uevir,r n�bale ciu,ck direr.tly (rom the <br /> Clly of EveretL <br /> � ,�ss;gning payment of th�� F3ar.k�a�ater Prevention Dt�vir,e rehate to thc Vendor <br /> �����cs rot exem(�t mc Iro�n l3acRv�aler P�evention Device Reb�te Frogr�,m <br /> �equnaments � <br /> I :ri'hr,n;�, �h�� �c!e,c:� ��f iny ii�l��ite In frn.: Ver.dui h:;�er, on p�iyE:� h;��u uf lt�•is (onn <br /> ��.onr!iny .iE,��inv:d rf ih�-� i urn��lutuJ L��3ck�vritr�r I�rcv,-:iifi�rn L)wic�� rcu;�h� �mckaye by �, <br /> ihF� C_ty �,� Fvet�tll � <br /> . <br /> . <br /> ,+�:> >;Y I � `i- I � <br /> . , <br /> - — ; � -�--- -- — - -- - <br /> S;gnah�re nl Propertv G��:�ner i�aro <br /> F'nge 1 c'2 . <br /> Ir..;, �ed f�';2f11.� ' <br />