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Backwater Prevention Device Rebate Program <br />� Rebate Applicatior� l�orm <br />-- — — -- � -- ---- --� <br />Property Owne� Name: STL' �L � � �� �� �`� <br />InstalL•dion Address' �� � � ��r ��� <br />Clry:� ��1�_L /� Slate: �Z��! Zip: ��L!•� � <br />Mailing Address (if dillerent)' <br />� City: _ <br />State: <br />Zip:_ <br />� Email: Phone: ( <br />Total Cost to Instali Device (/rom conlractor invoice). S_�/_� <br />) <br />(� r5' I, <br />Plesse verify the followin .• <br />/ <br />� I am lhe ov.�ner of the property where lhe backwater prevention device v�as installed. <br />J_—iJ I �vorked wilh the contractor lo determine the localion for the backwaler prevention device and <br />understand that lhe decision regarding the location of lhe dewcc was mine. <br />�� f�y contractor inslrucied me how to access, inspecl, and maintain the device. <br />p I und�rstand tha� I am responsible for maintaining lhe backtivaler prevention device and keeping <br />it in good workmg order, uNess il is inslalled in the city right-of-way. <br />,[1 If ! �ell my property, � will make polential buyers aware of the back�vater prevention device and <br />the need to inspecl and mainlain it on a regular basis. <br />[]�am enclosing all of Ihe necessary {%�per::orh (use the yello: Rebale Submitlal Clu�cklisl) <br />Select from the foliowing: <br />�j�The contractor idenll(ied downspoufs or other dralnc3ye umes ihul were connrcted lo my seever <br />line (behvicen my heuse and IhE installed device) and removed, or rciauted lhern. <br />[� To my knov�ledge, my properry has no do�vnspouts or ulher drainuyu conneded tn my sewer I!ne <br />(belween my house and the installed device). <br />[� There are doemspou�s or olher dramage lines connecled lo my sewer line (bet�veen my house <br />and the Inslalled device). I under.;land lhat leavin9 these conneclions creaees a nsk of flocxiina <br />and I accept thal risk. <br />�L -, � J <br />Signature �?"'� � � �` Date / �I✓�Il�,� � Jr � J <br />