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�y�� ° �-; '�. . t`i .�� 4 1 € •' aaa .:� ��f �� �; _ £f� <br />R .:. � . � * . £ � <br />�� iSs�> �i�� , <br />�"�' f�� S a�3 �. .i-,� + �'� �,� . 3 �: .. � i � <br />�.n� �. <br />Property Uwn�r Name: � ✓ �- __ <br />lnstailation Address: � � � �--'� ��� �" �`�' ����- <br />City. � L� � State: ,�,� r� _____ ��P=- "�, �`�-�''� � <br />"�w7 1 �.. ��C-��` �-� � ���f <br />Mai(ing Address (rf different): � <br />�-.- � <br />Giiy: 9�-� State_ --��. �ip: <br />Phone: ��j .� ��� � "�c�c�� �, <br />Ema91; <br />7 <br />otal Cvst ta tnst�U deuice (fram eontractorinvaieej: $ ��" �i� -------- <br />�,. � . _ � � ,� <br />� l am fhe owner of #heproperty wh�re the �aekwaier p�eventian device was insfalled. <br />j�i worked wi�h the c�ntractor �o determine the iocation for the bacCcvvater prevenfiion device and <br />under�tsnd thafi tha decision regarding the locatian of the device was mine. <br />�7 �y contractor instr�cfed me how to access, inspect, and maintain the device. <br />I understand tha� 1 am responsible for mainta►ning the bac4cwater �revention device and k�eping <br />� it fn g�ad working arder, unless it is installed in #he city right-of-way. <br />If 1 sell my property, l wi�� maf�e Ppt�ntiai buyers aware of the back�nrater prevention device and <br />� the need to inspect and maintain it on a regular basis. <br />I am enciosing atl of th� necessary pape►�rvflrk (use the yellow Rebate Submiital Checklisfi)- <br />� <br />�e6ec� fr�� the ��31��uing: <br />❑ 7he contract�r identified daw he ir�s� iled dsvice) �a deelmoved,�or re eut d them� to my sewer <br />line {beiween my house and f <br />�-a t..�� ��g�t�d��, my prOpet�y has no downspouts or other drainage connecfed to my sewer fine <br />��betvueen my house and it�e instafied device). <br />� There are downspouis or other drain�g hat leav n� these ca nect9ons c're�tes a risk of fioad ng <br />and the inst�lied device).1 understand 9 <br />and 1 accept that risk. <br />�' . �� ,�,,1 �,y <br />� D��� � — <br />Sa��a�#ea�� <br />