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- f, � j ':�� tr';' � 3 - � 3. �* � � '�� 1 , � <br />� 1 <br />� <br />, _ � ,� ,: j . �� „ � ��: ,� <br />� <br />Please use this Invoice Cast Breakdown as a template for invoices submitted as p�rt of the Baekwater <br />Preventic�n Device rebate program_ Either this form c�r your own invoice form with the follow[n� line items can <br />be subrr�itted. This a{lows yc�u fo invaice your clier�t according to your existing bi(ling templa#e while allowing <br />cify staff to identify how costs eligible for the Sackvvater Prevention Device Rabate were accrued. <br />Only labar and materials directly related to ihe installafion and function of a backwafer prevenfion <br />device are eiigible for City rebate and fherefore should be included on the upper ha(f of this form. <br />Additional costs may be added to 6oitom of the form, <br />,�,�� --, "�,�� �, <br />Business Name.,���'�--r.;-���'-t�� '`�`'f'}�?rt`�t?�License Number: t`�%��������.'� <br />_ _ ,�-�, �.. _ <br />Business Maiiing Address: <br />State �ip <br />Phan ��:,.�.; J �� � �-.,�,�, Email:{�' .� tk- �; l� � �i����`t�__�-.�-�='���-�i�,� �,�r ��"�'"'> �'c:�:�3'� <br />e: ' � <br />Revised 9/03/2014 <br />� <br />