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'Op <br /> ielsoeum <br /> vital <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: `(,2-2-/ <br /> Owner Name: J)-166'G.- Va rG ' ' er6424-- <br /> Backwater Valve Address: I,I ? e%.frwre ,4v� <br /> The backw er valve installation is complete: <br /> Yes ' No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and f nctional: <br /> Yes No ❑ <br /> You were ' n instructions and training on how to maintain the backwater valve: <br /> Yes No ❑ <br /> You understan that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes No ❑ <br /> Signature a h06 Date // /97)7 V <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />