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1W3oAvn <br /> till"°4411"mailimAilli <br /> *laid <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: Mool 253, ZO 111 <br /> Owner Name: em.r)14_ I tp\DI_ <br /> Backwater Valve Address: 5-0 5C) Ruc-k ex Av%-c _ <br /> The backwater valve installation is complete: <br /> Yes a"---- No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes e" No ❑ <br /> You were giv n 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 /> ,�/ <br /> Yes IlJ:f No ❑ <br /> Signature ` Date S - 2 0 I l{ <br /> Q-..--; -.7 <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />