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I <br /> Backwater Prevention �evice Rebate Program <br /> Rebate Application Forrn <br /> - - �pl�....�Fx�P� ll�l� U�tA- � ��l�t ' <br /> ; Preperty Ormer Name. t � t I I <br /> I Irstailatlonkddtcss' tL'IU4 (!�IO�% L'Vt':1���1�/Y� ' �4/e' _ , <br /> ! City �C.Y�i State. r�l,�_ �ip: 1U�-0� i <br /> ' 1603 S� � A � <br /> � Alailing Address (J diEerent)� l �r��' �I '��17 ! <br /> I ,I <br /> k�,� .�`1 � �Q�'• � • � <br /> ' City. 1'��".r�� 1.11�1� S;ate �,Zip:_n – — � <br /> � <br /> � Email. 0���. V11 P-�'� 1�(����?�l P�one: (�i9��i ��� I <br /> I � <br /> ITelal Co�s11 �o Inslall Cec�ce (f.•om cror,tracto��nvace): 5 _ � � <br /> � � � <br /> `--- —--------------- -- -- -------- � <br /> � <br /> Plaaso veri(y tho following: <br /> % ; <br /> :� I am iM1z o�mer o(t1�e prop�r.y wheae Ihe Cacnv:ater przv=�t�on dc�Cc \L'a5�i15Ia�I0� � <br /> '� I 1•:C14!0t��'+ilh I'10 COft�(2UOf I�dc'C�T711�B Ih8 IJSdtiOfl �Of IhC OdCkN3t�f pt�VElllipR(}OV;CE 3Rd � <br /> under;land thal Ihc decis�n regardinn the iocatio� o(the device tivas mir,e. � <br /> � i <br /> j�fi �,1y conUador Inslruc?ed me how W acczss, irspeq, arW mainlain Ihe device. � <br /> �; I urde�stand thai 1 am r9sponsiblz for mainlaining lhe baCkwater prevenUon device and keeping E <br /> it In good ��.n�ng �rder, uNess u is inslallea m ehe �ity nght-c[-�ry. � <br /> U✓ I� I setl my property, I vrU rttake poteni�a! b��er,aware ef the B3ckarter prevention dee�ice and <br /> Ih> need to Insped and mafntain it on a �egut�r basis. � <br /> / f <br /> V�'I I am enUesir,g ail of ths necessary pap�rrr�rk (use:ne yellow Reba;e SubmRlzl ChecicAst). i <br /> Scloct Irom tho following: I <br /> ❑ Th�con;raUor iCenti6ed tlownspcuts or o,her drainaga Il�nz, lhal were r.anr.eciad to my se•,ver � <br /> {�ine (Cetwh=n my house an�Ihe insfailed de�4ce) and remevzd, or rerouled Inem. i <br /> To R�y k�av�led9z, my pro�rty ha4 no downspculs or olher d�afnege corneded lo my s�efer line <br /> Ibel�vicen my �ou;e and Ihe insa��ed device). <br /> ❑ The�e are do��nspouts or o:her dreinagz lines cannect�U lo my ser.er haz (9elween my house <br /> and lne in5i�tied device). I unders;and ih31 leaving th?sc: connecbons cmales a iisK o1 Oooding <br /> anA I �r.cept In�l risk <br /> Slgnarure ..l� ��� il Nl.'•� '��/I�� e– �vVl��bl �Y/�C1�V�� <br /> V � u <br /> . � <br /> i <br />