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��ackv�raater F'revention Device Rebaie Program <br />Vendnr Paymeni O;�t�on Form <br />Project Number: <br />(Ciry ro Provldel <br />Please complete both sides of tne form <br />Propetty Owner 5ection: <br />Property Owner Name Qhw I� S. C�w f�[✓1 ��,�c< <7 in s,} ----�` <br />Insta�Iation Addrass _�� Z D j—�ZN:i-2� _7�Z �!_— _-------- <br />c�ry: =vc�g�.IT_-- ------s��E. - l'''-`'_-- ---I'u--yS� � =� — <br />Malling Address (r/diHeranli --_---- __---,_---.T �_ I <br />Crty: <br />^___ State <br />Z�G __ _ _ _. <br />Email' _,--- --------- — Phone ( ) <br />� <br />Total Cost to Install Device Ifiom contracla �nvnicep S_J? �'�__. <br />I, the propeRy owner r�quest to have the City of Everefl Rack.vater Prevenuon Device ret+ate r,heck <br />for the installation of the dFr�lr,e at the atove referenced pop�rty addre5s he made paya6le to, and <br />SOflt 10, ih0 vBOdof S�Rc�@d Ou ihE b2Ck of tltis iOrm By requesnnn, W�e rebaie check be maue <br />payable to the vendo�. i ag�ee tu ihe fcllrnvinp. <br />1. I wili not receive a rebato ctie:k dlrectly (rom the Glty of Evereri. <br />2. Assignmg paymait n� Vie 2bepe to Jie vendor cloes r r� e.9�ipt me f�om !?ar.h�:�aie� <br />Preven[iun Device Retale Proyr,m �eGuirements. <br />I aUlhorize Ihe release af my rebate ro the vendor listed on !he back oi Jii� foim yendinp <br />approval of �he completed Barkwatar Prevemwn Device �ebate pacnet hy the City of Evereii <br />�"� � ��, �. -- <br />Sigr,aWre oi Property Ovmer <br />��9-/� <br />�ate <br />u <br />n <br />