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. QAT <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: 3 2' , 2014 <br /> Owner Name: Ai•A) 14cc e--f f,0r(-) <br /> Backwater Valve Address: I T25 Oa-i.e S <br /> The backwater valve installation is complete: <br /> Yes 'Nl No El <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes ISI No ❑ <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Yes 0 No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes E No ❑ <br /> Signature AMili 3ttW✓itN Date c.(i 1 ( <br /> 5:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />