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o Av„ <br /> "441.111V <br /> BACKWATER VALVE ACCEPTANCE FORM <br /> Thank you for participating in the City of Everett Backwater Valve Program. <br /> Date: Man 20, 20i4 <br /> Owner Name: Ck,,,q,,,,A�� �— �1V`c bu,N, <br /> Backwater Valve Address: 2;Z-j Jvn wo:.. 4 pe.- <br /> The bac water valve installation is complete: <br /> Yes [ No ❑ <br /> You hav been shown where the backwater valve is, and the flapper assembly is currently in <br /> place a functional: <br /> Yes No ❑ <br /> You wer given instructions and training on how to maintain the backwater valve: <br /> Yes No ❑ <br /> You under tand that you own the backwater valve and are responsible to maintain it in the <br /> future: <br /> Yes No ❑ <br /> Signature Date <br /> R ft) g--65 )'16 ij*.ke‘. 211/1/' (i>nD( 4,1 <br /> Dot, <br /> S:\GMoen\Backwater Valve Program\Backwater Valve Acceptance Form.docx <br />