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Backwater Prevention Device <br /> �� Property Owner Rebate Form <br /> Please verify the fallawing items: <br /> r�am ihe ov✓ner of the property served hy lhe side sewer where lhe Backwater <br /> P�evention Device was installed. <br /> l I �vork.ed with my contractor to determine the installation location for the Backwater <br /> Prevention Device. I understand that !he final decision regarding installalion lo�ation <br /> was mine. <br /> ;[(�If the dackwater Prevention Device vdas installed on my properry: <br /> ` ' i have heen shown how to access, inspecl, and maintain my device by my <br /> • contractor <br /> . I understand the Ciry will not maintain the 13ack�vater Prevention Device. I <br /> am exclusively responsi6le io maintain it and to keep il in good workiny <br /> order. <br /> • If I sell my properly, I will make the buyer aware of the Back�vater <br /> Prevention Device and the need lo maintain it. <br /> Choose one of the following: <br /> �' ,As of nov✓, my property has no downspouts or other onsite drainage that connects to <br /> the side sewer upstream of lhe installed Backwater Prevention Device. <br /> or <br /> ❑ I still have doti�nspouts or other on;ite drainage that connects to the side sewer <br /> upstream of the installed f3ackwater Prevention Device. I understand that leaving ihese <br /> connections means ihat the risk of flooding from downspout or onsite drainage remains. <br /> I accept that risk. <br /> Siqnatu`re / ��`�v/ ' C Datel � y/ 6� Z� l� <br /> t.. - ,/`t...L' <br /> Page 2 of 2 <br /> Rr,vised 09�091201a <br />