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�,�� Backwater Preventi�n Device Rebate Program <br /> �M�„_._ Rebate Application Form <br /> .��„ <br /> - -- ----- - - - - -- � <br /> � Property Owncr Namr. __� �_�C'�!.�-- - - -- -- -- - - <br /> - v- -- -- <br /> I Installation Address __a�_ _- ��'4�-� <br /> Clty. - -- State _ _ -___ _- Zip -- ---- ---- <br /> Mailing Address (il drNerent�. __ ---------- ' <br /> � City _ - - Sta�e: __ - ___— Zip- _ - -- - --- � <br /> ------- - / I <br /> Email: --- _ -_ - - - --- . �j <br /> _ F'honc�S�3�� `�Oa� <br /> I Total Cost lo Inslall De.wce (Imm conhactonnvoice): $ _ �c?_�_���� <br /> I -- -- - -- — <br /> i_ -. _— - _ - ----- <br /> Please verify the following: <br /> �m lhe owner of the property where Ihe hackwater prevention devlr.e was installr.d. <br /> [�worked with Ihe conlractor to determ'ne Ihe IoraUon for the backwatm prevenfion dewcr, and <br /> unAerstand that the deasron re_yarding the locat�on ot the device was mine <br /> (IX My conlraclor instrucled me how!o access, msper,t, and m�mlain Ihe dewce <br /> [j�understand Ihat I am�espons.ble for maintaining lhe backwater prevenlion device and keeping <br /> it in guod working order, unles, d is installed in ihe city right•of-way <br /> �sell my property, I will make polenlial buyers aware of Ihe bar.kwater prevention de�ice and <br /> Rie noed to inspect and maintain it on a regular basis <br /> I iL'� I am enclosing all of lhe necessary papenvo�k(use Ihe yellow Rebale Subm�ttal Cher,khsl) <br /> V " <br /> Select irom Ihe following <br /> �� The contraclor idenllGed duwnspouts or olher dramage Ilmes thaf were connucted to my sewnr <br /> line etween my house anA the installed dovico) and removed, or rernuleA lhem <br /> ( -o my knowledge, my properly has no downspou�s or olher Arama�e cnnnr,cted lo my 5ewer hne <br /> (belween my house and Ihe installed device). <br /> � ere�re dnwnspouls or olher draina�e lines connecled lo my sewer line (L•etwer.n my house <br /> and the installed device) I understand that leaving these conner�ions creates a nsk of Ilondina <br /> and I �iccept that risk. <br /> Signafure_��-� Date �� ' 3=.7 �� �J <br />