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�A�KWATER PREVENTI()N PF20GRAM <br />iNVOICE COSY BREAKD►OWN <br />Please use lhis Invoice Gost f3reakdown as a lemplate for invoir.es submitteu as part of the Backwater <br />Prevention Device rebate program. Either this form or your own r�voice form wilh the following iine items can <br />be submitted. This allows you to invoice your clienl according to your exisling billing template while alloveing <br />cily staf( lo identify how costs eligible for the Backviater Prevention Device Rebate were ar.crued. <br />Only 12bor and materials directly refated to fhe installation and function of a backwater prevenfion <br />device are eligible for Ciry re6ate and therefore should be incfuded on thr upper half of this form. <br />Additional costs may be added to bottom of the form. � <br />p 5�'G�I'r L �•, i <br />Business Name;Hy/1�rc,t� � '�C.� �r��P License Number: �:� <br />Business Mailing Address: o((c�-{c LGc ("lc l�l 1J lt-- Q=(/i%/ .�.�`+ ����+ <br />City State Zip <br />Phone:�Xo`.�/C� "�?�� [mail: i r�nnl�n�c-n���S-�;n�j ���N�CNr,Y`(: C'ciYY/ <br />Revised 9/03/2014 <br />