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Ba��Cwater Prevention Device <br />Rebate Program <br />Invoice Cost Breakdown <br />1�eYm��'� Nb. <br />r� r y �I-o�9�5 <br />Please use this Invoice Cost Breakdo�vn as a template for invoices submitted as part �� the Backwater <br />Prevention Device rebate program. Either this torm or your own invoice form �vith the (ollo�ving line items can <br />be submitled. <br />O �ly labor and mate:ials directly related to the installation and function of a backwater prevention <br />device are eliglble /or City rebate and theretore should 6e included on the upper half o( this /orm. <br />Additional cosfs may be added to bottom o/!he torm <br />T�ZCoKI/ac}Oy',,{-,LG L�L•� SMZCOLL S�S�P%L <br />Company Name: � 7 93Z '10����� ,� UBl � h�_�_,5��'-2-v a Date: ��' �%"I.5 _ <br />Property Address: !' 6` � �D ckc{II l/� r�✓�,, _Fvc ra h;. WA 9�.ZJ <br />Revised 17111/2014 <br />