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. ; <br /> Backwater Preventia�7 Device <br /> �� R�bate Program <br /> � <br /> � <br /> � <br /> 1='��r ir7tt�rri��l Use_ f'tr��r�ci Niu�itE���,�: <br /> V�ndor Payment C)ption Form <br /> Please r.omple#e tzoth sides of the forn� <br /> Properfiy Owner Section (please prir�t): <br /> � ,t } <br /> �t�"r'�� �Y`�..�"',yl��,�:�_ , <br /> - ---___._. ... . ._ . _ ._ . _____ � <br /> Pro� erty Owner�lame .. � <br /> i� �� .�L��;�� .�;" � � <br /> Property Address C;ity Stat�: !i�> <br /> Alfern�ate Nfa�iling Address �ity Slatf� %i�, �:��� <br /> i' <br /> . .__ _ __----- ---___ __...__.. _ _ .. ._ � __ . <br /> , <br /> 4 <br /> PhQne F�rT�<3il � <br /> _..._. .__.___ _.__� � <br /> ____ _.___.._.._ _ ._ _. _ _ . _ <br /> � <br /> � <br /> � <br /> (, #he Praperty Owr�er, request (o hr�ve fl�c;Gity of Evc�reli Backw��tc;r I�'►�c�vc�niian !:)c.;vicc� �' <br /> rebate check for the installation refc�rc�nced a! lhe Pra���rfy Addres:� h�r �n;�dc� �><�yal�lc: <br /> to, and sent to, the Vendor. By requestiny th�c inceniive/rebai�:� cfit.ck f�c; n7��cic; Er�y�hlc: <br /> to the Vendor, I agree to the following: � <br /> 1. I will not receive a Backwater f�re;venlior� Device ref�aiG chc:c,k ciiec�ctly fi�c�n� lhc: <br /> City of Everett. � <br /> 2. Assigning payment of the Backw�ter Preve►�fiion Devicc� r�b�-�tiy tc� il�c� Vendc�r � <br /> does not exempt me from Backw�ler Prevention Devic;e Rek���io f'rc�c�r�3n� � <br /> requirements. <br /> I aufhoriz� the refease of my r����tc. t� the Ver�dor list�d o�� ���gf� twc> c�l tl�is fc�rri7 <br /> pendin.g approvaE of the �otn��leted E3�ac.kw�fer Prevention Dc<vic:i, �c:h��i�� ;�<�t:k����c; ►�y 3 <br /> ft�:.� City of Everett <br /> �--, <br /> ''��4:� � ,. <br /> .', r��rttir<. of f'roperty �wner U<11r: <br /> I'si���� 1 c�l 2 i <br /> I•:����I�:t��i �i-:i;'?f)1=1 <br /> , <br /> � <br />