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� � ; � � 'w_ • �; :��- �: <br />dw t�> ,�� � ' �a <br />� �i ? <br />-: , <br />� , � . <br />! � ,� 1 � R �i. 'i <br />� E� �� <br />Piease use ihis (nuoice C�st Srea4cdown as a temrPfa��e �ur own �va e fa mdwthphe folVowigg I ne tems can <br />prevention Dev�ce rebate prog�am_ E{t��r this fo y <br />be submitted. This a{lows you to invaice yau ga'ckwater�Pre enfiion Devi ce� Reb�ate we e accrued�e aHow�ng <br />city staff to identify how costs elig�ble fQr the <br />pnf tabor ancl tnateriats directly ralated io the instatlatron/ � U� � o�� ��� � p p� ��� o��is forrn� <br />Y <br />device are efigible far City rebate and f�irerefare shc�uld e <br />Addifional cosis may be added fo batiom of the farm. �, �� <br />��'��..'�'- -r y� �!e_G7 <br />Business Name:_� � _ <br />�'-� : �.� ";�,�-'._ ��� License Number: ���_�-� ��`� <br />. .: �:,�, (..,�.'z � �� �--r � �t� l' �' �� �,�� <br />Business Mailing Address: ��lr% �itY State Z�P <br />o ��• <br />xr�� �'�ai�� '� �r�� �.�J;-r i .e'�, �.t5 � <br />Phone: ;��`�� `� `� t,��:�,._—.�_.._— Email:�� � �; ��r � .�f',t~r4 r��-�r� 4 , _ � _ , <br />Administration Administration I man <br />L�bor CCTV lnspection <br />gWV I'ns�all <br />1V�aterials <br />Rentals <br />Fees <br />Eti ibte io�ia <br />Other Gosts <br />Ineiigible Total <br />�----- <br />Totat _ <br />Surface restoration <br />Site cleanup <br />Downspouis I drainage imp_ <br />Bacfcwatei' vaive <br />G�inder pump <br />Side sevuer pipe (up to 8 feet) <br />Imported Sackfifl <br />Surface Restoration Materials <br />(top soil, grass seed, concrete, ete. <br />Cover {irrigation box or laad bearing <br />cover) <br />Specify equipment <br />t <br />.--�-�`". �— <br />i ni�r,nGai fees bv ite►n <br />fees if not covered <br />.- � v� � , �,,, <br />Costs not assac"tated <br />not eligible for rebafe <br />Revised 9/t}3/2��4 <br />labor <br />, a�d <br />Uni�s <br />Hours <br />Hours <br />Nours <br />Nours <br />Haurs <br />Per Unif <br />Per Unit <br />Feet <br />Yards <br />Lump <br />sum <br />PRr Unit <br />Yards <br />