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American Septic&Sewer 425-252.5674 p-04 <br /> 5 <br /> Backwater Prevention Device Rebate Program <br /> 4:7r Vendor Payment Option Form <br /> i <br /> 9t <br /> 3 <br /> Project Number: (City to PrOvtde) j <br /> Please complete both sides of the farm <br /> Property Owner Seal= <br /> Property Owner Name' <br /> 3 <br /> Installation Address:_„_;)n_() . <br /> �” State: ►A)� Zip: � � k <br /> City:_ �� <br /> Malllrig Address(It diffemnt): <br /> state:��Zips <br /> EMIL Phone; ( ) <br /> F. <br /> Total Cost to Install Device(tram cvrrtractorlOcice)r$ <br /> 3 <br /> 7 <br /> I,the property owner,request to have the City of Everett Backwater Prevention Device rebate check f <br /> for the Installation of the device at the above referenced property address be made payable to,end <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor,I agree to the following: t <br /> 1. 1 will not receive a rebate check directly from the City of Everett. <br /> s <br /> 2, Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Preventlon Device Rebate Program requirements, <br /> a <br /> • g. <br /> I euthortze the release of my rebate to the vendor listed on the back of this form pentiing <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> i <br /> Signature of Property owner Data <br /> ( <br /> 1 <br /> 3 <br /> 4 <br /> i <br /> 3 <br />