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10 rim 577 <br /> #1401111',..A4 <br /> vogi <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: Mod `1 , 2314 <br /> Owner Name: Moor t.e,_, Aa.rn i 11-01n <br /> Backwater Valve Address: 3O6 4 laLt, <br /> The backwater valve installation is complete: <br /> Yes -i 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 No El <br /> You were given instructions and training on how to maintain the backwater valve: <br /> Yes -NZNo ❑ <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes No El <br /> SignatureV-- Date I1 <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />