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eildmAma <br /> *414G1 <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: MOul I f <br /> Owner Name: c <br /> Backwater Valve Address: IL (S" Iio,i 1, o� <br /> The back ater valve installation is complete: <br /> Yes I 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 NoIr <br /> ❑ <br /> You we r: given instructions and training on how to maintain the backwater valve: <br /> Yes IA No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes No ❑ <br /> • <br /> Signature y 1Ak Date <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />