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i <br /> Backwater Prevent n Device Rebate Program <br /> Rebate ,,pplication Form <br /> ��� E" I -------- <br /> �- ----- ._.. - - -��-----;�_ ---- � <br /> ' Prepem'J.vnei laame:_�U a l�.��i ji�i R�-.�� c.q �I-n�a.]7 w: c. ��_ <br /> i I� � I <br /> � InslallaLon A.ddress'--Li> 1 O IZ .=c �-'e"� , � <br /> �----�;�Z��— ---- <br /> c��y; L.�;..._.,.lN _ State: l.tJ�---`�P-�`--- -- ! <br /> i ---- — .r + <br /> - MaiGn9 Addre,s pl ddicrent%'__ . I <br /> � -�-------"--'------ <br /> � } � <br /> State��.-----[m: . � <br /> I CitY'----- ------ ^ - . <br /> � ' <br /> EmaiC Co�n� Z C`= lerrP�vz. h ,'L Phn�tn' :yv_,} Z �Z�/� " ' � <br /> f - . ---�-----.' <br /> p i <br /> � Total Cest Ic In;la�l �evite�(rom co0fracNr iq��c�ce): 5��(}_�_O�__—T � <br /> I-----�'-- -- -- -`----('--------•'--`�--�-----' I <br /> Please verify Uic following• 1I � <br /> ��ain the owner ot the nroparty where the ba �.v�aler Crr,v�ntion de��ir.e�vas in5lalle�. � <br /> [✓I 7:O:keC Vlilh th@ con�r�r.lo• (o tlet�fnlltiv'th Vor.at�on torthe b3[kwater prevenlio�device 3rd � <br /> understan��hat tne tlecision regardino the I ahon ot the device was mme. <br /> i i ta�y contrac�or tnsi�uc�ed me i o�v te access, �spect. anh ma�ntain the dev�ce. ' <br /> �j I unCastand Ih:i:I am�es�.onsihle for maint. �+In� li�e nar.kwat�� p�e�.ention device and ke?ping I <br /> d�o good wnrkin�oroer. dniess R is nuialle �me:ity�ighlo(-�vay. I <br /> [�If! scll my prnperty. i w�ll make po�ent�al Lu 'S aware of the�acKwater prevention tle�ice and <br /> me reed to mspect and rr.amta�n it or,a re9i �� oa`is. ! <br /> ��I am endosing all ol Ihe necessary•GaPerwo� I�use lhe yelio�v Rebale Su�mittal Chechlist�. ( <br /> � <br /> i �Solect (rom thc followiag: ' � <br /> rj 7he ronlr;r.lur�dentihee d0•.vnspouls or olh 4�ainay'e�LneS thnf KCR'�JMCC:ed lo mq SCwCr I <br /> line Ibetwner my tu�use and Ilie instai�eu d 'tr.)and remuved.ni r��wi�ted Ihem � <br /> �TO mV knowleUge arv nropeny!�as no-dow �uouts cr oihe�Or[�inage tonnerte:t�o my se�verline I <br /> jbetw��en my house 2nn Ihe�nclalled dev�r � <br /> �_� Theie a�e downs�outs or olher araina,ye lin ,cannected lo my sewet�ine(t�eha�r,en nry house <br /> and mr�Inslalle6 dev�.rej. i undersland ihat I rving ihese connecGon;cruale: a ns6 ut qcndina <br /> and I acr.ept thal dsk <br /> '� � i <br /> ��i��—���_ -�--ZCO" �> I <br /> ISi�nlfum��_ __ '_n.t:� _ <br /> i <br /> I <br /> I _ .�.____ _'_ ___�.— <br /> . . . . . . "'". . . _ _ .. .. __.. . � . <br /> I � <br />