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BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: , 20l <br /> Owner Name: \- e . 1i' <br /> Backwater Valve Address: 1511 Ru..d 4v' <br /> The backwater valve installation is complete: <br /> Yes IN No ❑ <br /> You have been shown"where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes ts, No ❑ <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Yes No ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes 4 No ❑ <br /> ,' / � Z. '((( <br /> Signature Date <br /> S,\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />