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SACKWATER PREVENTION PROGRAM <br />d INVOICE COST BREAKDOWN <br />Please use lhi5 Invoice Cost Breakdovm as a template for invaices submitted as part of the Back:vater <br />Prevention Device rebate program. Either this form or your o�vn invoice form wilh the following line items can <br />be submitted. This allows you to involce your clienl according to ��our existing billing ;empiate v�hile allowing <br />city siatf to identify Itom� costs eligible fof lhe BaCk�vater Provention Device Rebate veere accruod. <br />Only labor and materials dlrectiy related to the installation and lunction of a back�vater prevention <br />devlce are ellgibfe for Ciry rebate and therefore should he included on ihe upper half of this form. <br />Additional costs may be added to bottom of the form. <br />/���_II� �j� ���s B'�1 � S� <br />Business Name:fl�XJG�Ie�iG1'���u"'`��-- License Number, \ ___ _ <br />Business 1�iailing Address: <br />�}�3 �3C �� � s'w. �i��7� �� �gO�6 <br />rCity State/� Zip <br />Phone: �L:L. (, (�S —1� 1�f � Email:�Shcw�$'y�1�^� n.�c}� S'eu.���,( w��.lai �.- C D�� <br />Materials <br />Administration 1 ma <br />CCTV Inspection <br />BWV Install <br />Pipe replacement <br />Surface restoration <br />Site cleanup <br />Downsoouts / drain <br />Side se�:�er pipe (up to <br />Imported Backtill <br />Surface Restoration Mt <br />;;oA so�t,_grass seed, a <br />Cover (irrigation box or <br />Rontals sp�ciry eqwprnen� tt4 uo+. � <br />--_ - —_ oR�^'—�5— uCKS- rt'_�'`� — <br />Fces Disposal fees by item ___ __ <br />Delivery fees i( not covered by labar <br />--�-- -- — <br />Eliaihle Total I _ <br />not <br />Other Costs � not <br />Incligible Total <br />Total <br />Revised 9/03/201d <br />with BWD, <br />(delail helc <br />Units <br />Hours <br />Hours <br />Hours <br />Hours <br />Haurs <br />Hours <br />Hours <br />Yards <br />Lump <br />Per <br />ou <br />a0. 0a <br />