Laserfiche WebLink
,� <br />ev err <br />Backwater Prevention Device <br />Rebate Program <br />t ��r 1i.1 �tn:d Ut,c: "n����r�:1 i�iinil��,� <br />Vendor Payment Option Form <br />Plcase completc hoth sides of tlir torm <br />Property Owner Section (please print): <br />S�?"it,k j �� �-'Zlct`C- <br />Property O�.vn r Name l <br />�?�{��LC K�_rc'c-��� <br />Property Address �,t�, <br />/1ltemate P.taiiin� Address <br />Phone <br />S�;dc 7,ip <br />Cdy ..---_—. .-Slab: Zip <br />-- -- f_mail------ <br />I, the Property O�vrer, requcs� �o havc: Ihc Cily of [vcr�:ll [lilf.ICLV�31i�r I'revenlion I)r.vicc <br />rebale r.her,k for Ihe installation referenceci .d (he Pro�r;�rly l�ddress; I�e ni�di� ��rryni�lr, <br />lo, and sent to, the Vendor. Ry ieyuest�i�,� tlie ;n�_enliv� �/iel�alc cli��ck lic in�uie �i,�y;ibi�� <br />fo the Vendor, I agree to ihe (oilotivinq <br />1. I vdill no� reCe(ve a Back�vater ('iuv�:��tinn D��w�:�� rchrilc clicrh dnecUy Lon, (Iu� <br />City o( E��crett. <br />2_ Assignin� �iaynienl of fhe l3ack�v,ifer I're��ention Device rebale lo Ih�� Vi�ndi�� <br />doos nol exempt nu: (rom liar,k�;�alEx f'revunlinn I�evu:�� Reb��c Pro��rnni <br />icquiremcnts- <br />I authorizc lhe relr�ase ot rny n�bn�e fo lhu Vendur lisled on �rigc Iwo ol ihis fixm <br />pendiny nppruv.al of Ihc r.urnpl�tted Ci,ickwri(ci I'icveniiun Ilevir.c icl�,ilc �r��:k,i��c li�, <br />lhc Ci�y nf E��e�clt <br />i: ,,�.,,I^ , i:t; <br />_ y �z� �zo,s <br />,�;,,,, <br />��,,.,�. � , i:� <br />