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BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: tM Zg', 2-0tW <br /> Owner Name: Koko tt 6e5Y1 <br /> Backwater Valve Address: 42110 t exraco_ bi , <br /> The backwater valve installation is complete: <br /> Yes No El <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and functional: <br /> Yes l No El <br /> You were given 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 /> Yes r'ri No ❑ <br /> Signature Date 2 (C4 <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />