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i <br /> ��" Backwater Prevention Device Rebate Program <br /> Mi�-r Vendor Payment Op�lon Form <br /> �ro;eU laumoer --- �(City to Pr�vi�'e) <br /> i--- <br /> Please complete both sides of iha (orm <br /> Property Owner Seclion: <br /> 1--- -� n' � ^ 7 ,� � ,� �Fj�-1 � <br /> Prepe„y C�•mer t�ame. �V�IY� I`���.;��� I,�.�V'� �,/./�-- ��" � � I <br /> � Ir.stallation Aaaress �� i�f � ���� 4��I���'� ���;' �'/1�`��• I � <br /> ' Ciry. Clj 5,��t'A�S _ ;a �I �� rp: "I raG'�/ I � I <br /> S te. r� <br /> j f.tailing ,+.ddress (il difMrenf). �� V�� (�� � ]� _�`�-� ! ' <br /> I I <br /> � Ciry �a1ef(Zr'" ?S�cU�t(�._.. siate: 4U�`i Z�p `� Cµ0 ` <br /> i e�,a.�: Ic11Y1>rnPa'���� o, iYial� ,f,�YYl Phene. (dGV ��lj-,�1`� i � <br /> To!al Cos! lo Ins;ail D<vice flrom cun:rac5rinvoicey 5 � � <br /> �---- � <br /> -- --------� � <br /> _ — , � <br /> 1, Ihc Dfcp�iy av.'RE'f. fP.qUe51 IJ h:1VP. ;he Ciry c�Evere;i Back:�:a�ei Przvzr,uon Dev��e reba,e c�ecM1 �� <br /> for�Ae installa6on of lhe�evice at lhe auove ie'erenced pcoperiy addre,s De madc GOYahlz lo, anci <br /> s=M to, lhe vzrxlor spec�f ed on tl�e Dsck of ihis to:m. By �equesling the re5ale chect be maae � <br /> payab'^_ to tne ve:�dor. I agree lo Ihe tollawsng i <br /> 1. I vrilt nat recc��r'v � reDafe check difeCily from Ihe C�ty ot Everell. � <br /> ?. /�ssi9rnnq payment o(;he rehate lo Ine vendor does not ex�cipl me !rom 8ack��ater ' <br /> Pieventicn De��ce ReGa�e Prog�am raouiremerds. � <br /> . __ i <br /> � I autnoize ihe releasc ol my rebate lo lhe verdor I'sled on lhe back ef this (�rm perdin� I j <br /> � approval of !he comoleted Gack�vater Prevent:o7 Device reba:a packct Ly the C�ly ol Evzrelt ' S <br /> i i <br /> � ""_ � � � � � <br /> , <br /> � ��.�,�. M�'.��; ;���j� '� t;�Gl`�'1�--- , �c� -��,�ol ; � <br /> � v •� � - ,,,r_t i <br /> Sian�ture ol Propeny U�mer U�" . I <br /> �-�----- - --- ---- � <br /> ( <br /> , <br /> i <br />