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ZS/O1/�D15 1]:?3 �:5.525176 STA <br />��j; Backwater Prevention Device Rebate Program <br />�»• Vendor Payment Option Form <br />Projeei Numbec (C�(y fo ProvttleJ <br />Please complcle both sides of the (orm <br />Property Owne► Section: <br />Pnc,� u�ie�� <br />Propr.rty Owner Nnme� ��i E ��t i.i �i�.-L «� 4.% fi -�'fl�' �� L C C� <br />Installation Addres^,. _�2 � f� �1 i-^_ �� 2� _ <br />Gry� �J ° �? � State (n1 � Zi - <br />D <br />CJlaihng Atldress (ild�llerenf) �-P �� ��� � �� � <br />G�l'. -.+1�� �r�� Slala t�� 7,p� "{ R O I S <br />_,-i�-�'� � ''1 Phone ( `i � '1'� f 3 �y' � <br />Frnall. �1'C �'�^�I � t <br />�orl Co51 to Instalt Devlce (/rom Confreclar invoice): 5 <br />I, Ihe propCrly Ormer, requesi to have Ihe Ciry cl Everetf BacMvalc• Provrminn nevicc renaea �heck <br />lo� the insfallafion of the tlev�,ce at �he above iEferenced oroperty address be maye payable to, and <br />sent to, Ihe vendor specifetl on the back of th5lortn By reaueshng the reba!e chetk he made <br />pByahle to thn vandnr, I apree lo Ihe follav�^-y <br />t. t w�'�I nol rece�ve a reb�tr. check mrectly Gam IhC Gty ol Everetl <br />2 Assigning payment o! Ihc rebate lo Ihe �.entlor does nnt eKempt me irom Backwater <br />P�evenUon Device ftebate Program rcqwrements. <br />I eUlhOt�2e Ihe rCl�ase 01 my rebate In Ihp vpn,i�r hsted on Ihe back of th�c (ortn ponding <br />approval oi lhe completed 6ackwaler Prevertion Device rebale packet by the Gity of Fveretl <br />, . �-- " �� IJ <br />`.iL`�C. —`___-_ —_ <br />SIqI1B1UfE OI PropChY OW ner D, to <br />