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11/F5�2�15 �::p1PM 4253536607 NCP�E GROVE RV <br />1Ii0d/�Ut6 7:31 I'tl F.L� 12fiJJ5dJ70 PAGE 02/b5 <br />CBaDGell'6 P1W7bio6. IDC ({a OOOJ/o009 <br />Ven <br />Property <br />property <br />AltemNte <br />Phone <br />E3aGkwater Prev�enti��n Device <br />Rebat� Program <br />for Intam�,l Usc: Prajert Nurnbor, <br />Payment Option �orm <br />Please complete bofh sides oF the form <br />vner Section (please print): <br />-------�� <br />Slate ZiP <br />Slato lip <br />I, iho Prop�m, Ownof, requeSl to have the <br />rebale chec(� (or the installation referenced at the Ero rett Bqdhmss befm deJ�n Devi� <br />to, and sent tol the Vendor. By requesting the incenti e1 b2le check be ma�+p ae3bin <br />to tho Vendor, I agrao to the fofiowing: P yable <br />�• ��vill no��eceive n BaCkwater Prevenlion Device rebete check direcfly from the <br />City of verelt. <br />Z• �9fgnlr�Q paymeni of ihe Beckwller Preventioi� pavice rebate to the V�ndor <br />does nof exempt me from Backwater Prevaniion Oevice Rebate Hrograrn <br />roqulrerr�ents. <br />I authorixe th � relcase of my rebate to the Vendor listed ort pago two of this form <br />pendin� appr�Ial of the comple+tod Backwator Prevention Devlce reba;e package by <br />the City ot Evyrett <br />S;gnelum <br />ReviaoA9l3f20ta , <br />I <br />Owcer <br />., , ��_ <br />Date <br />Page t ot 2 <br />