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� Backwatr_.r Prevention Device Rebate Program <br /> Vendor Payment Opti�n Form <br /> Preject Numbec —_ ---- --- ICity fo Pmvide) <br /> Please complele both sides of the form <br /> Property Owner Section: <br /> r - - <br /> -- --- -- <br /> — _ _ - -- <br /> IProperty Owner Name: �'— p� f`us _ <br /> Inslallation Address. _p�'`'��� _iL_ ti� .�i� — <br /> t,� �/11 <br /> CiIY ��1'_�_� State: w� Zip:�Gi/""� — <br /> Mailing Address (il diHcronf) _ ___ _ <br /> City __ _ _ State' _- - —_...—Zip'_ <br /> EmaiCqriqS �vr,�-eM6�/G(d'1Ni� CJY✓1___ Phone' c f"'1 �✓DI__OOc7�7 <br /> J __ <br /> Total Cost to Install Dr,vice ((inm r,onfrar.fnr invnir.r,f $ — _ <br /> I,ihe property ovrner, reyuest lo have the Ci�y ol Everelt dackwaler Prevention Device rebale check <br /> lor the installalion of the device at ihe above referenced properiy address be made payable to, and <br /> sent to,the venAnr specified on Ihe back of lhis form I�Y fP.(�UP.S�IfIQ�I1P. fP.hOtP. GI1Cf.I( I1P R17AP, <br /> payable lo the venAor, I agree lo Ihe following <br /> 1 I will nut receive � rehate chec.k direr.tly Irr,m the Cily of Eveie�t <br /> 2 Assignmg payment ol lhr. rcbate lo Oie vnnAor does nol exempl mr. from Oackwater <br /> Prevenlion Device Rebate Pragram requuements <br /> I aulhorite Ihe rrlease ol my iebatF��lo Ihe vendui lisled on ihe back of thiti (orm periding <br /> approvai ol Ihn completed BaJ kwater Pmvention �ewce rehate packel by the Cily oi Everelt <br /> / <br /> "' - _�- -- -J-� y � - <br /> Signalure o( Prnperty Ownr.r Date <br />