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� <br />� <br />Backwater Wne Re'bate�. Form <br />Proper�Y � <br />please verify the following items: <br />I am the owner of the property served by 1he side sewer where the Backwater <br />Prevention Device was installed. <br />�orked with my con!ractor to determine the installation location for the Backwater <br />Prevention Device. I ur.derstand that the flnal decision regarding installation location <br />was mine. � <br />� the Backwater Prevention Device was installed on my P�oPefh'� device by mY <br />.; I have been shown how to access, inspect, and maintain my <br />contrector <br />� am exclusi elye spy wilh eoi mma'ntainhe ad t keepPr �v9oold o king . <br />order. <br />. If i sell my propeAy, i will make the buyer aware of the Backwa er <br />Preveniion Device and the need to maintain it. <br />Choose one of the following: <br />As of now, my propeRy has no downspouts or other unsite drainage th2t connects to <br />the side sewer upsiream of the installed Backwater Prevention Device. <br />or <br />[] I still have downspouts or oiher onsite drainage that connects to the side sewer <br />upstream of the installed Backwat� "revention Device. I understand that leaving these <br />connections means�that the risk of'..00ding from downspout or onsite drainage remains. <br />I accept that risk. <br />Date �'� <br />Signature - <br />Page 2 of 2 <br />Revised 0910912�14 <br />