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BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: J AMP 61 , Zoo/ <br /> Owner Name: oI ar er yLela- <br /> Backwater Valve Address: I 1Oq ( A-lees b4ve <br /> The backwater valve installation is complete: <br /> Yes C2 No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes EV. No ❑ <br /> You were giv instructions and training on how to maintain the backwater valve: <br /> Yes No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes No ❑ <br /> Signature - Date /?/2�� <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />