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i <br /> , i <br /> Ba�:kw��tcr Prcvei�tioi� Dcvicc � <br /> Fvr�e�r �C�)�j((' {�I OC i illll I <br /> —� � t <br /> r <br /> i <br /> I <br /> Vendor Seclion (plcasc ��rinl): � <br /> _ .. . � <br /> _� ' s` <br /> � �i.:�J"''��. L. : .o ��r��f i/�-rJ , �� � / l i i� I �% � I <br /> Vendnr �'ainr. /Itu:�nus,; N�uur. / I1111 I�hinduri � <br /> ����_�!. I ', �j�• , r�lr, I <br /> S101e Of W:c:luni�f�m (:nnlrni:lui I.u:un�;r f�hunh�ri � <br /> �� . i � . , � ,r I <br /> ���_ �__..f�' �: � ��' �/�.✓r � r/ t'f'iV;� fl '/� � / .l � <br /> ��;. <br /> VCndOr(��eilini� /�ddicss (:ily :;I:dr. /i�� I <br /> •Z' � ,/�� i � . i <br /> ���_�:—�. . � � . . . / "'.�.� / j��/��'�•'r / /11'1` � !�. 7 r/..J ./'� „ . . i <br /> Phone 1 iu,nl i <br /> ----- _ . ( <br /> I, ihe Vendor, :�yic�� lo rer.r,ivc lhc l�ar,kw,ilci I'iuvunhoii I)ev:r.�� ichnlr. r.licr.k �lucclly � <br /> for Ihe inslallalion referenced �t (he I�ro��crly i1<1d�ess Ry :igicciny lu i�:t:r.ivc Ihu ir.li,ilr. � <br /> check direcUy. I ,iyi�re lo Ihr. foiie,viny � <br /> 1 ihe 13ackw�l��r Prevuntion Devic�� ir.t�ole nnwunl will I�r. dcdur.lr.rl fi�im Ih�r linnl <br /> invoice givcn lo Ihc Properly Ovaner foi Ihc inslall aliun ,il Uic ('ru�icrty Adcti�� : ; i <br /> reterenr.r.d nl�ovc, if Ihe �Mal co;l ol Ihc installalion is yru;Um Ihrui Ihr, iclydr. : <br /> ?. I, Ihe Vend�ir, :91i!d VV8511111(�I011 S1�11C lia�nsc�l cimli,�r.l�ii ( <br /> 3 iht:� Cily nl I v��rcll will scnd a f'��duril I i�ini 111D!1 W11tiC In in�� Ilir. V�:nilnr. Ini j <br /> flic l3ackwalcr I'ievenlion Devicc rebate p,iynianls IuLihny inwc Ih;�n $(iUO pw � <br /> calendar ye,ar. and will reporl Ihe ::amr, p,�ymenls In Ihr. hilr.m:d hevr.nuc i <br /> 5eroicc � <br /> ( <br /> i <br /> I accepl Ihe duecl p;iymenl of Ihe 13achtvniei Prr.venliun I)c�vicr. relriie lioni lh�t t:ily ' <br /> i <br /> o( Fverell p��ndini� npproval ol Ihe r,oin�ilclr.cl Il;ir.kwnlcr I'icvcnli��n l)evicc ir,li;ilr. <br /> pEick�r�c I�y Ihr (;dy of I_vr.iall t <br /> � <br /> � ; <br /> i i <br /> / ' , <br /> �.'� ,.�'i�, � �l � ,�(, �: �- j� _ < , ; , � <br /> ,";1;jn.ih n c nl(-r rnl r.u !r u 1).�!�. • <br /> i <br /> i <br /> _ j <br /> i <br /> � <br /> I <br /> i <br /> „. � � ' i <br /> � <br /> � <br />