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tSt r <br /> '11111011°A <br /> *40a' <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: Met.i.s 20 , 201 L( <br /> Owner Name: (i � �s-e - Lax- <br /> Backwater Valve Address: y 3 21 Krcicemm��' . <br /> The backwater valve installation is complete: <br /> Yes No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes ] No (l <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Yes g_ No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes 2L No ❑ <br /> Signature Date 6� ?.A // <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />