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Backwater Prevention Device <br /> E� r Rebate Program <br /> I'or inicin.il U�.c� I'�-�y��i:l (vwul�r� <br /> Vendor Payment Option Form <br /> Plcase completc both sidcs of Ihe forni <br /> Property Owrar Section (pleasc print�: <br /> 1J(C-�C-C� �,?� - -- - -- I <br /> Property O�v��r Namc <br /> _1S'ez �vc��2 _t}-Ljt� <br /> Property Address . C:ty - -- - _. SL�Ic _ --.1ip _ <br /> Alternate Aiailiny Address Cily Slale 7;p <br /> -- -- -�--- - ---------- -----... - ------- - - <br /> Phone Em;id <br /> I, ihe Property Ov.rer, requasl to havr. Ih�� City o! f_vcretl (3ackwaler f'revr,ntion Ucvu.r <br /> rebate check (or Ihe instalhlion ieferenccd at �he ProFierly/lildies; be m�ulr. ��;ry;�hie <br /> to, and sent to, tlie Vendor Ry requesiuu� Ihr, mccnlivc/rcbalc � I�cr,k I�c in;ulc ��,ry,ildr <br /> to the Vendor, I agree to the following: <br /> 1. I will nol receive ri L3ar.ktvater Prr,venfinn I)evir.e reb�;e check din:r,lty from thr. <br /> City of Everett. <br /> "l. �s:;iyning payment of Ihe H�ckwatcr Pievenlion D�vir.c icbal�� to Ihr. V��ndn� <br /> does nol exempl me fium Li;ichvri�ui Prevention I)ev�cu Rebale F'riu�i,�!n <br /> i�quirernents <br /> I nuthome lhe rcleasc of rny rebate lo Ihc Vcndor lislr.d on psiqe Iwn ol Ihis lunn <br /> pendiiiy ;a�piov:�l of lhc �:omple(i�d f3tu:kN�alci Pievcnfion I>r•vir.c iclirilc ��nck,n�r, i�y <br /> Ihc Cily of Fveretl <br /> V�-'li�1 J -2 3—� � <br /> ti�gn;lluru c�G'ic,pr��ly O�tini�r U;rtc <br /> I�n�i�� f ,�� :, <br /> IG,vr�.��l !i�:11�'111�; <br />