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� <br />� <br />Backwater �'rever:�ion Devi�� <br />Prnperfy Owraer Rebate Fori� <br />Please verify the foilowing items: <br />�I am the owner of the property served by the side sewer where the Backwater <br />revention Device was installed. <br />`y� I werked vdith my contrac!or to determine the installation location for the Back��iafer <br />Prevention Device. I understand that lhe final decision regarding installation location <br />�vas mine. <br />�j I( the Backwater Prevention Device was installed on my property: <br />o i have been shown ho�� to access, inspect, and maintain my de�dice by my <br />contractor <br />I understand Ihe Ciiy �vill not tnaintain lhe Baclaa�ater Prevention Device. <br />am exclusively responsible to maintain it and to keep it in good working <br />order. <br />If I sell my property, I will make the buyer avdare of lhe Backwater <br />Prevention Device and the need to maintain it. <br />Choose one of tl7e following: <br />� As of now, my property has no downsnouts or other onsile drainage that connecls to <br />lhe side sewer upslream of the installed Backwater Prevention Device. <br />or <br />❑ I still have downspouts or other onsite drainaye that connecls to the side sewer <br />upstream of lhe insEalled Backwaler Prevention Device. I understand that leaving U�ese <br />r;onnections means ihat the risk of flootling from do�vnspout or onsite drainage remains. <br />I ar.r.opt that risk. <br />Siynature( �'vk_�����2�� Datc �' �� ,��'��If— <br />/ <br />Pngr,'l_ n( Z <br />f Zr vi ;ed 0 J/0912U 14 <br />