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BACKWATER PREVENTION PROGRAM <br />a INVOICE COST BREAOtDOWN <br />Please use tHis Invoice Cosl Breakdown as a tempiate for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Eilher this form or your c�wn invoice form with the tollowing line items can <br />be submitted. 7his allows you to invoice your cllent according to your existing billing template while allov��ing <br />city staff to idenlify how coSts eligible for the Eiacktvater Provention Device Rebate wera accrued. <br />Ur�y labor and materlals directly related to the installation and /unction of s backwater prevenfion <br />devicc� are eligible forGlry rebate and there(ore sho�ld be included on the upper half of this form. <br />Additional costs may be add2d to bottom of the form. <br />Business Name: AbS��Jt'`RM�"�C'"�e�- License Numl�er: ��S°IS} ��� <br />Business fVlailing Address: <br />���23 �36�'� s� Sw �'��e�s �k-1- qgoa6 <br />q,�> Cit nState ZiP <br />Phone: �/✓'�' ��S''��7 Email: �� wi��5�'1a»�5�2��5� G''k°i � �PP'1 <br />Revised 9/03/2094 <br />� <br />�� <br />