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3 o rn 5/' <br /> 'Olt Tr <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: i ei 9 , 7 d l L <br /> Owner Name: i i^j�� 0 � <br /> Backwater Valve Address: 110 2 o0,60' -ct , _ <br /> The backwater valve installation is complete: <br /> Yes 1 No ❑ <br /> You have been shown where the backwater valve is, and the flapper assembly is currently in <br /> place and;functional: <br /> Yes ] No ❑ <br /> You were given instructions and train keg on how to maintain the backwater valve: <br /> Yes M No <br /> You understand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes 5 No El <br /> Signature 14,vitkA; &kit"— <br /> Date 5/61/ <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />