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� <br />�" <br />Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Properly Owner Name: <br />Inslallation Address: oZ�O n I �Q i�✓I i Pcr' it112 � <br />City: _�\/ .�0 i-% State: �_ Zip: � S a D l <br />Mailing Address (il diHerenl): <br />c�cy: <br />State: <br />Zip: <br />Email: 1�CXGf Vl n P(G ✓1�LI(`i'�'LI i7lrOS�e� Phone: (� �-{ IR —{.,8��- <br />Total Cost to Inslall Device (Irom contrector invoice): 5 <br />Please verify the following: <br />� am the owner of the property where the bac�water prevention device was installed. <br />[v� I worked with lhe contractor to determine Ihe lo ation for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />Q� My contreclor instructed me how to access, inspect, and maintain the device. <br />[v�l understand that I am responsibie for maint�iining the backwaler prevention device and keeping <br />it in good working order, unless il is installed in the city right•of-way. <br />[lf If I sell my property, I will make potential buyers aware of the backwater prevention device and <br />the need to inspect and maintain it on a regular basis. <br />� am enclosing all of the necessary papenvork (use the yellow Rebate Submiltal Checklist). <br />Select from the following: <br />❑ The contraclor identified downspouts or other drainage Ilines thal were connected lo my sewer <br />line (between my house and the instailed device) and removed, or rerouled them. <br />[� To my knowledge, my property has no downspouts or other drainage connecled lo my sewer line <br />(between my house and lhe inslalled device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the inslalled device). I understand that leaving Ihese connections creates a risk of (looding <br />and I accept lhat risk. <br />Sionature 1 � � " � Date 2Z— �� <br />` ��XC�1lirCL`� Gf/�9� � — o'�`t —/� <br />� U <br />