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,.,x�...;" �,^ � ,� ?..,.. !� ��'i !� � �� � ?�� ��- .,�� <br />�: � <br />�■, � �� . ` � � '� •� �f p� <br />`M*����� � f� � � 1! <br />piease us� thi� Invoice Cc�st Breakdown as a tempiate for invoices submitted as part of the Baekwater <br />Prevention D�vice reb�fie progr�rn- Either this form or your own invoice form with the fallowing line items can <br />be submiffed. This allovus yau to invoice your �clienf accordir�g to your existing biliing tsmplate while allowing <br />city staff io identify how costs eligible ft�r the Backwater Prevention Device Rebate were accrued. <br />Qnly labor and materiads directty relat�d to ihe installa#ion and fernctic�n of a ba�ckvv�ier prevenfion <br />device ar�e eligible for Ciiy rebate and �h�refore should be incf�ded on Phe upper ha(f af fhfS form. <br />Addrtional cosfs may �� �d��� �a boitom of the form. �� <br />�'�'E:.t�-'"'� i <br />Business Name:. ,=� ; '�a ���_, '=�' ��'� Licerise Number: J,�' L��' <br />Business Mailing Address: <br />Sfate Zip <br />`� � ` �:'�5,�-______ Emaif: �� ..�' '<�., � d�' - ..t : �':''� ? <br />F'hone� �' ` <br />. ��.� � <br />, <br />Revis�d 9/03120�4 <br />� <br />