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�N� �aaicwater Prevpn4ion L1eviGe Itebate Program <br /> F�:7 Vendor Payment Qption Farm <br /> Proi��f N�.:mb9� _ _ �C:ly�0 P�n:dtl?i <br /> .�.._ <br /> r�eeSe co�iipiei@ buiii S�iieS U�iiie iunii <br /> Property Owner Secfion: <br /> ----- J _�- !Mo . ------ ._ <br /> P�openy O�.vn=�Na�ne. � `t VV 1 0� <br /> � instal�atwnHhtlrass� _1 /l�' rLIG��✓ _�U�'eKk'� <br /> 7/ �}1}r� � ��p�/�� � <br /> r <br /> � CII7�. �/�"t. I , _ Sl'ulE _�!=•1_'_— ��P'_— � � <br /> � I�4adirg Addrecs h7 diAeienp: ___ __ <br /> City� �/� State: _ Lp._ _ _ <br /> � [m�il��l.-1=—Y�/�AU/V� 5 l� �,(GTINGi f�� . (�P�.ono� IZW) �J���1(J J ��; <br /> � 7r,ial Cost to Install Devi�2 �6om conoactor invoiceJ S _��Y ! / ��___ <br /> i. Ihe proF��b� ov:nzr. r�cuesi to n_rve ttie Gty o( Ev2rs;t Bac,vaater Pravenlron Dewce rebate chect: <br /> (nr Uia lnstallat�on o�Ihe Uevice at Ihc abOve relerenced property adtlre;s be made payable to. and <br /> sent ro the vendor speaGed on the back of lhis form. 6y raquasiinq the rabate cheCk be made <br /> nayable lo the venAo�. I ac�ree b the foliowing� <br /> i I a;dl nct rec=ive a reGate check dvectly from ihe C�.ty�f cvere(! <br /> Z Ass�gning pzyment of the rahals +o ihe vendor tlo25�oi exempi me hom Backwaler <br /> ' PreveMion Oevice Rebate Proaram requuements. <br /> i aulnorize the retease o�my rehate lo U�e ventlor listeo on ihe �acR ot thus form pendinq <br /> approval ot R�e comoletetl Bad:viater Preveiil�On Cl@��iCP �Bbate ndrb?I by lh4 C�ll'OI EvnrCt� � <br /> / � <br /> ----- -�- - �—�"`'--- 3�3U='-S- <br /> ' S�gnawre oi Prone ��Owner pate <br />