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a w � �.� � °�€ � <br />�' .�. � . .= . �; �; <br />� ` ' � � � <br />� . <br />� <br />g ,� f� ' 6� ��� ���� d �,�� � <br />�' <br />a � z <br />�'s'� f Q,i , v' � r I <br />Please use th4s invaice Cost Breakdown as a iempiate far invoices submifited as part of �he Backwater <br />Prevention Device rebate prograrn. Either this form or your own invnice form with the following line items can <br />be submitted. This allov�rs you to invoice your cli�nt accarding tc, your existing billing template while allowing <br />cify staff to identify how costs eligible far the Backwater Pre�ent[on Deviee F�ebate were accrued. <br />�n1y tabor and maferials direcf�y relafed to the tnsta!latian and funcfion of a backwrater prev�ntion <br />rlevice are eligibre for City rebate and therefore should be included on fhe upper hatf of this fat'r�►. <br />Addiiiana! costs may be addec! to botiom of the form. <br />•-� � �'�'� �- ��.'�...�`� <br />Business Name:�;��1���-i �'��t-� ��f3.,� _'v `� � � L cense Number. _ f .�'��`�''�����`�+ <br />Business Mailing Address: ���%� � � �°`�4 �Y �� U� -�� �f"'��.�R � �'�� �`� �`��� �' <br />Cify State Z►p <br />Phone: :�:,�'.��(� � ��'"�"�`��-�a -- Email t'� ���_�=--�r�i��Y� ir�� � �-������.� �-,��� ���t €'�"a �'�'�3'��',� <br />_, <br />Revised 9103/2094 <br />