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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAlCI)OWN <br />Please use this Invoise Cost Breakdown as a template for Invoices submitted as part of the Backwaler <br />Prevenlion Device rebate program. Either this form or your own invoice �orm with the following line items can <br />be submitted. This albws you to invoice your client aa:ording to your existing billing template whfle ailowing <br />city staH to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />pnfy labor and maferials dJrectly related to fhe instaNation end /uncHon of a backwater prevention <br />device are eligible /or Clty rebate arM thercfore shou�d be included on the upper haN of this form. <br />8usiness Name: <br />Business Mafling Address: <br />Phone: �I2 S ��`�i '" d �Z <br />License Number: �%�f uL�O / / A/� <br />City <br />= {=v.et2� �w 9d�ti� 3 <br />Revlsed 9/03P2014 <br />