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� BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Pleaea uee this�rnofce Cost Breakdown aa e template for invoices submilted as paA o(Ihe Backwater <br /> Preve�tlon DevkB mbale program.Either this tqm or your mm involce fofm wllh Ne(ollawing line rtems Can <br /> be submittad.This allows you to Invoice your clienl according to your exfstlng billi�g lemplele while allowing <br /> � city staHto identity how cosls eligible lor the Backweler Prevenlion DeoioB RebdtCtvere ecaued. <br /> � Onty labo�and meMnals direedy relatod ro the fnsh/faUon artd/unefien oI a becAwalerpnvention <br /> devlce are eligibla!or Ciry rebafe and there/ore should be lncfuded on the uppe►AallOi thfs/o�m. <br /> Addifbne!costs may be edded ta bof(om o/Hre form. <br /> ���l� f�j 'Y7K6 <br /> Business Name' P-nCl+� �a�-i�q-����e�e Number. <br /> ac <br /> Business MeiGng Add�ess:�j�f'Ln �.U.I`li r� Q� EJ'UL.�{" t��Q.s�A�_ <br /> City State �p <br /> Phone:`n�t(Y�^'o�R�l�l�gd EmBiI:C�:ndiQ.LL1'IC "(`.a��Cl�'�`'^�'%��''�Si-�1a4•i�7'_/:CL`/!7 <br /> C�k Dmeri Non Units Quanti Rale 7elal <br /> AdmlNstration AdmMlstration/meneaement Mours <br /> Lobor CCN Ins edion Mours - <br /> BVW In81n11 FIOurs <br /> p�pQ �e�� Hours <br /> . 3urfeceresloretion Hour6 <br /> Sito dcan Hours � <br /> Down ulsldrefn eimp. Hours <br /> lAaWAals Backwalavalve PerUnit f ' <br /> Grindcr ump Pe�UnN <br /> ake sewsr roe(u ,o a faep Fee� o <br /> �mport00 BackfiA Yards ` t <br /> Surfaco eslnr�tion Meteriale Wmp <br /> � soA ss saeC oonaele c. sum <br /> Cove�firrigationboxorloadbeeriilg Pe�Unil <br /> cov,r i � <br /> Rrnkats S dy eQutpmem �� <br /> tin� -��� �+� a <br /> Fses O��poral faeu by llem YarAe <br /> pnlNe fees It not oovereO b le0 r - <br /> G. .fo0 .(00 <br /> EB IEIs Tatai f <br /> ON,x Costs Costs nOt essoUatetl wiN BWD,and <br /> twl al' bte for rebala detail balow <br /> Ind' @�e7obl f <br /> Totat <br /> Revised 9/0.2/2014 <br />