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: �a�k�rater 'Preventic�r� �v�ice lRe�t� Prrs�yyrano <br /> Rc�b��e APR�i'cativn For+m <br /> r�o�r�� �wwr„�r r�e���: ;'r + '�-K �� a't�.-��.1�� -- -- <br /> ���E���o�;.�d���� t��;�: �:,�,-� . �- rau� <br /> City:�-'��.�� i�' t"� S1ale� '�s_) � . YIP; � � �L1 --- — <br /> Mailinr� Aakir�as E�c�tflererif!: , , - - - - <br /> Cily: S1a�2: . - _ -- iip: <br /> ; ` <br /> �m311: ti-s ���r.Lh�'���z �'e r �� �:F'r+D.i 4 • C E1`i i�hone: f�-��' ��A�+' _�� �-`�� — <br /> � To;al Cast to on�fi�it �ez��cp (�!�orn ��rr�i�orzRVuicF): 5 � <br /> � <br /> Pletise verify the (ol�owing; <br /> �I sm ihe,x�+rt�r ot it���rop�}r wlnere rn�h2ekwate� pteven�on tlevice was.I,�staue�. <br /> �'l worl:ccf witn the c�ii�v�eto� td �eter��ifne tlw Icx:aUur� ►'o��taas t�ari,watar prcrrei ition devlce at�� <br /> urxl�rsland i�ai 1he deClsio�r�paedirg the t�c�liun ai t�e devi�:wAs mine• <br /> � <br /> �0.9y �ontracior 6nstruc9a�i ma hot�•to arx2�, Insp?r�t, and� maln�l� th�E devi�, <br /> � �.�r��9er5t�n�J th�t ( �m ce6p�ansib7a for rnai�naalninr th��aack��atQr �ro�:entlan �e'��, a�d keaplrog <br /> i1 u� 3upcl �vnckine arr�,r, uiti�F�S n i� Ii�stnllc�cS in Eh4� r.iFj riyh;�oi•r��y. <br /> (�."Ii i r.�3U�my �xopPrt��, I +vill m�ke ;�atoni49� hu�� �w9re qi �h� hack:vater prsven�ion aeviGe and <br /> tfia n�ed to inspet� a�i meint�ira it on d feoular il�aa;s. <br /> �`�I am eitclusi�g a�i �F tl�e ne�s��iy {�iaper�,�.�nk i��se tl�a yutia�v d�cUaie ,�u��lttr��Clixkldsfi). <br /> 5alacc rrom thE follo•�ving: <br /> / <br /> L �t►e ca�Uactor idenc�fie� dn��ns�its or ott�r d+�a6•�age �uRcs t�tiat w��r��onnected tu +ny sawer <br /> li�oe (be«v�:�n m:,�hpa�s,� ar��i'rhe i�astalk,d de+riee) and remo�+ed, vr rervut�+thez� <br /> �To mp�:ntn�Aed�e. m}� t�r�,�zrty h�at no dcti�nsspouts ar�nthei drTi�age c:�nF+ected t� �y ���+�r IIn9 <br /> jlfet�,l�n i»y 61a��sa a�xJ tl��U�s43lled 6cvlC�ea. <br /> [�7 `tA►t�ru E�iQ iia�vribpoul� a� b'I�tct aTi�ii�5ag� lirus ut+flnodoi� I.a riiy sowcl Itne,[buh��i� ciry l�ou�u <br /> arx.i the 6nsl�llec��evit�l, I und�rstand tha6 ileavirrg these aonnectior�s cre�es a risk of floa�ing <br /> 911t� I �CCE!p7 lt�c�l ��'t'.+k, <br /> � r• � r�� , � <br /> Srgnafer������� v1^�--�yz,C�. �ate,_,��,��� <br /> `" `l <br />