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/ i�gackwater Prevention Device Rebate Program <br /> �j� Rebate Application Form <br /> �c <br /> i r, n � �7 <br /> P�operty Owner Name. /' vL 31^� ()INL�E � li.fi'A ! .a/7�,`1G��� /)Crti�� — <br /> In5(dllaliOnAddresS � ��� �[r�� �✓� <br /> Clky ��.F-�j_/ State � Z�P ���� <br /> �ilailing Address (ildiHemnf): '� _ _ <br /> City: State._ Z�P: <br /> emai� �� ,���/l�� E��`'!.'/G . [i71`'1 Pnone: �4:�5 3>"%'-(,�/�S.S <br /> — � <br /> Tolal Costto Insiall.Device(Irom contrectorinvoice): 5 � fGG• � ___ <br /> PI ase verify the following: <br /> I am the o�vner of lhe•properly where ihe backwater prevention device was instailed. <br /> L; I wo�ked�wilh Ihe c,�mractcr tu determine the location�for the backwaler prevenlion device anU <br /> unaerstand lhal the dedsion regarding the locatlon of Ihe device was mine. <br /> f� My ecniraclor instructeA me how lo access,Inspecl, end maintzin the device. <br /> �J I undcistand that i am responsible fcr malntainbig the back�vater prevenhon device and ;ceeping <br /> d in•good working order, unless it is�.installed in Ihe clly ri9hl•of-w3y. <br /> '�J If 1 sell my proFerly, I will make potentlal buyers ar�are of lhe backwaler prevention device and <br /> � thc need lo.lnspect and mainlain il on,� regular besis. <br /> '�] I em enclosing all of the necessary papervaork (use the yellow Rebate Submiltal Checkllst). I <br /> Sel�ct from lhe followinc�: <br /> i] The conlr3crof Identifietl tlovrnspe�ls nr mher druinciye Ilines Ihal v.�re con�iecled lo my sewer <br /> line (�etween my house arxl Ihe inslalled device) and removed, or rerouted Ihem. <br /> �� To my k�owletlSe, my properly��as no dnwnspouts or oU�er dralnage wnnecled lo my sewar I�nr: <br /> (lxtc,een my house and the inslalled Aevico). <br /> ❑ There are tlownspou�s or olher drainage lines wnneded lo my sevrer line(belween my nouse <br /> and the Inslalled device). I undersland lhat Ieaving these c:onnecUons creales a rlsK c(800diny <br /> and 1 accepl Ihet nzk. <br /> Signature__L��—"" i� Date_ �/ I� <br />