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� <br /> 1' <br /> Backwater Prevention Device <br /> � <br /> Rebate Pr�gram � <br /> � <br /> f=�r i1�t��ri�r�l Usc.�_ !'�t�j�r��:l N�in�rlx:i: <br /> Vendor Payment aption Form ���� <br /> Please com��lete both sidcs af the form <br /> Property Owner Section (please E�rint): <br /> C��4-����...._ ��- �;�'� ���7¢� � <br /> Property Owner Name � � <br /> �f�� � ���c��.,�.�,�.,�°�" �;,.�-�. __ ��a.f�,.�`�_:�� � �� �-j���?�?� �: <br /> Property Address City 5talc� lip <br /> k <br /> -- ___ ,. _ j, <br /> Alternate Mailing Address �iiy Si��i�, Li�� � <br /> ° ` �': �.: � � ' <br /> �. '�.�� � �'�,�.�s:�`���._.___ _ .�—'�_��������.c:�� ��°,�.-�1 m ���� ,. <br /> � <br /> Ph0(12 �_fil��j� � <br /> ---.__._.�__ _. . _------ _�._.__...___ .- — - - � <br /> (, the Property awrer, request to hc2V(: �Il(; City of Ev�r�ii B�ckw��lc,�r f�'i cvc�n(ion Uc;vicc: � <br /> rebate check for the installation rc,fr.;rc�n�x:d al il�r; Praperty ndclres� fx� ui,�cir. C�r�y�lhlc� <br /> to, and sent to, the Vendor. By req«�sti��g it7e ir�ecntiv�/rebaie ch�;r,k ht: i����cic: �ray��l�Ic� � <br /> to the Vendor, I agree to the fol(owii�g: � <br /> 1. I will nofi receive a Backwater Preventioi� Device rebate cF�cck ciirc�cily (rc�n� lhe <br /> City of Everett. „ <br /> 2. Assigning payment of the Backwater Prever�tion Devic,e r�f�tatc� tc� ti�e Vc;ndc�r <br /> does not exempt me from Bat,kwater Prevention D�vicc Rc�b�tc� i'�r�c�x3r�3r�� <br /> requ:irements. � <br /> � <br /> � <br /> � <br /> ! autharize the release of my reb�i�� fo lhe Vendor listed on �ac�e twc� «1�tF�i�, forrn � <br /> �ending approval of the compl�:t�t�j E3���r,kwaier Pr�vention DE�:vir.� ir,�l�r�t{� �����a�:k�:igt; I�y <br /> the City of Evereft � <br /> � <br /> ; <br /> �>�,,--�� G�. ,�' �- c�. <br /> � <br /> � � <br /> __ __ - -- --- ----�---_ _ ----- -__._ _.___ `� �� �,� <br /> Sir�n�itiu-c of F'ropeity Owi�er l)�1<<; � <br /> I'ri��i� 1 t�l 2 <br /> I:�r��c�,,,��1 !ii:,;:�1)1�� <br />