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BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: INA,s 21 ZO t4 <br /> Owner Name: Atnclra. \oleS she rcA <br /> Backwater Valve Address: is 2S W <br /> The backwater valve installation is complete: <br /> Yes 1 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 (I No ❑ <br /> You wer 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 ,4 No El <br /> Signature ay rq -' pate mil�> <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />