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Backwater Preventio� aevice Rebate Program <br /> Rebate Application Form <br /> -------- � � <br /> ZY' � �SGL. �Y1� ' <br /> , <br /> '�r.�perty O.vn2+Nzme � � <br /> i Ir.staiiall�nAtldiess �'�-lU� �'�'l�� ' ) �'�1ti1�'}'�I�'f� 1�e • � � <br /> �,ry ��:��t/'� State. 1�� Zip: '+�C�=�1� � <br /> , tila�hng Add'ess fd drP,ercntl. ���V� �� �%�'�-'' ��' ���5 � <br /> II � I '�� ' II � <br /> Ci,y i�'t'YCk'.�'��'C�'!�h. S:ate �Z�p ��C. 1U i ' <br /> �n � � <br /> Email. __ �Urltl� i11w���� tir}'��� �wri �_Phone 1���2� .9-� � � <br /> � Tot21 Co`sl to Insiail Gev!ce tlrom conhaao��nvorce) 5 � I <br /> ' � <br /> i <br /> Plaaso vcrily tho Ioilowing: � <br /> '� ' am the o�nur ol lre proper.y where fhu trac�,�aler p:eve:,;,en tlevice rras insta le� i <br /> � I ,verketl vnth tlie conlrauor lo dzterm�na I�e locatinn tor Ihe Dackwater prevemion dev;ce nnd � <br /> underslant! thnt tNe tlecislon regara�ng Ihe IocaUon of Ihe Aevlce vias mine I <br /> f <br /> JMy contractor insWcteo me hrn•r io access insped, aM mam!a�n Ihe device. i <br /> ;� I imderslanA lhat i am respensible �or ma�nta�ning Ihe backwater prevention drvice and keep�eg <br /> d In good wcrking order, unlESs �t is mstaued �n Ihe ciry r�gh:•cf-�vay. <br /> L✓ II I sell my properry. I`�nll make potemial huyer;aware cf lhe backwaler prevention dewce an� ( <br /> ine nced to inspect and mainta�n rt on a regular Dasis. I <br /> (�; I ain enU�smg all ot Lh� necessary paperwo�k �use tt�e yeliow Rebate SubmRtal Checichst). I <br /> Scloct trom thc toliowing� � <br /> ;_j Th� centrador�de��l�f�ed aownspeuts or nther dramaye li�r:s �ha{�y¢re coni:cected lo my sewer � <br /> ;�ino (between my house and Ir2 instaqed dr.vice> erH7 �ema�ed, or rerouled Inem. <br /> 1 o my knav.tedge. my Dropeny has no dovmspouls or other drainage connected to my se�++er line ! <br /> �Cehveen my nouse and Ihe Installed deace) <br /> � The�e are dov.nspouis or o;her drainaoz iines connected lo my sev.�r lin2 (belween my heuse <br /> a��� Ihe v�staNed device). I undersland thai leaving �hese connecbore creales a r�sk ol Oooding <br /> antl I accept Ihal risk <br /> , f� � <br /> . <br /> T ' /�r� '`, ��J.( ' ��v� � (�'- �(v �O(j <br /> SlgnaturnJ� �,�l�l �✓r1l, ��B" (��b� � <br /> � I <br />