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5`:3 a pm <br /> "14010 <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: I 2-i , ZO(Li <br /> Owner Name: is1 v1 e..... C.o al eIUAi( <br /> Backwater Valve Address: 2-02-Z Roc_..e—t-ct i 14.,,- kit_ <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 /> Yew-,E No ❑ <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Ye , No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes'0--.. No ❑ <br /> )-' . <br /> Signature Date S o-/-- 1 <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />