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Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property Owner Name:-1�t�dr /t r/e�Ax1 ,G . CJQ <br />Installation Address: 020/ /7/DG r KGr r dyC <br />City: A51e State: Ar- Zip: <br />Mailing Address (if different): <br />City: <br />Email: <br />State: Zip: <br />Phone.( <br />Total Cost to Install Device (from contractor invoice): $ a YO Z <br />Please verify the following: <br />�am the -ow of the property where the backwater prevention device was installed. <br />jI worked with the contractor to determine the location for the backwater prevention device and <br />understand that the decision regarding the location of the device was mine. <br />13/My contractor instructed me how to access, nspect, and maintain the device. <br />B/I understand that I am responsible for maintaining the backwater prevention device and keeping I <br />tin good working order, unless itis installed in the city right-of-way. i <br />(,/If I sell my property, I will make potential buyers aware of the backwater prevention device and - <br />lhe need to inspect and maintain it on a regular basis. j <br />I am enclosing all of the necessary paperwork (use the yellow Rebate Submittal Checklist). r <br />Select from the following: <br />❑ The contractor identified downspouts or other drainage [lines that were connected to my sewer <br />line (between my house and the installed device) and removed, or rerouted them. <br />dTo my knowledge, my property has no downspouts or other drainage connected to my sewer line <br />(between my house and the installed device). <br />❑ There are downspouts or other drainage lines connected to my sewer line (between my house <br />and the installed device). I understand that leaving these connections creates a risk of flooding <br />and I accept that risk. <br />Signature L�Dafe 9 2- 2 — /Y <br />