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0°11111d=ma <br /> 444 ./tegi <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: Mal 72—! Za <br /> Owner Name: 1 i. t <br /> Backwater Valve Address: I IO Ruh.. ' <br /> The backwater valve installation is complete: <br /> Yes Digies No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes No ❑ <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Yes �o ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes Op/ No ❑ <br /> Signature C:1_, -\ � Date <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docc <br />