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BAGKWAT'ER PRE\/ENTION PROGf2AM <br />BNVOICE COST BR�AKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoicos submitted as part of the Bacicwater <br />Prevention Device rebate program. Either this form or your own invoice form v�ith the following line items can <br />be submitted. This allo�vs you to invoic your client accordiny lo your existing billing template while ailowing <br />city staff lo identify ho�v cosls eligible fo� lhe Backv�aterPrevention Device Rebate �vere accrued. <br />On'y labo� and materials directly related to the insfallafion and funetion of a backwater prevention <br />device are eligible for City rebate and there(ore should be rncluded on the upper half of this form. <br />Additionaf costs may ho added ro bottom o( the form. <br />5�����;. LL,�� <br />Business Name:,�71Pn�c�n��7.�- ��� License Number: _��7���� <br />Business Mailing Address: a�ie-(p Lu r��l� �� • 1`I/�'f'N L{�� �` ; �`3 <br />Cily State Zip <br />'. EmaiC ��) � � 3�1d�,ci�5���'� ���-�� <br />Phonc:��,'�IL�_y�0� . �a=Ll �ci��i-4 <br />Revised 9/03/2014 <br />