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� <br /> � <br /> � <br /> � <br /> B��kwat�r Pr�eventio�� D�ev�ce Rebate Proc�rar�� ` <br /> ���, r Rebatc A���I�i�c�tior� Forr�� � <br /> --- ____ _ <br /> � <br /> � � <br /> Property Owner IVame: �,.���)���� ��`-t�- 1 G�t-t�- <br /> fnstaflation Address: <br /> �`t �� ���' �'� .'� <� ' <br /> City:--__.___ St;�l�� Li�3; <br /> Mailiny Address (if differe�ltJ: <br /> City: :�i��tc: T_il,:. _ <br /> EmaiL __... �._-----._..... . f'faone: � ? ;. <br /> � <br /> Total Cost to install Device (h-oitt r,c�ntrru:(nr ��)voir;c): $ � <br /> ---...._.__ _._.-—-- __ _ _ � <br /> Please verify the follawing: <br /> �am tt�e owner oF the property wliere the E�ackw�tei���revc:ntiar� tievic�� w��s iri:;1�311e�ci <br /> [� I worked with the contractor to cietcrrninc>> the loc�a�iorr for the t�ackwatc:r prc�v��nGc�n c1��vir.�� ,�nci <br /> understanc� that the decision reqardir�q t#7c� lc�cation c�f the device v�-�s ���ir�r.. <br /> f' <br /> [� My cantractor instructed me how lc� ��r,cr:ss, ins��r;�;t, r�nd r2�t�int�-�in thc� devic:e � <br /> � <br /> [�I underskat�d that I am responsihlc fc�r in<�iril;�ir�inq il7e I�ac:kw�atc>r F�rc:ve�rilic.��� �i��vir.�r ;�ncl kc�����i��g <br /> it in goad working order, unless it is inst��lle�d in lh� ci(y right-oi-w��y. ;', <br /> ��Cf I sell rny �roperty, I will make �rotc�ntial buyc;rs awarc o((ht� backw��l��r��rcvcnli��n cl�:v�ci� ,ind <br /> the need to inspect and maintain ii c�n �� reyular (�asis. <br /> [�]'I am enciosing ali of ihe necessary paperwork (use !he yeN��w Rebate S�i(�niiU�il Chc�c:klir;l), � <br /> Select from the following: � <br /> �] The contractor idenlified downsp����ts ��r ot!}�-�r dr�in�:a��c Iiirtes tli�i( wr.r�� �:<�iin��r,l���i f�� nFy ����w��r <br /> line �between rr�y��ouse and the inst�311e�i c.i��vice)and rernovecl, �r rc:rc�u(ecl 11ie�ni. <br /> ("��To rny knowledg�; my prope�ty It�is nt� d��wi��sE��>uis«r��>ttter dr�,3inr3yc r.��nnt�r.i��ti l�� uiy r,��w��� linr, � <br /> (beiwn�ii my h�ta5e and the instr311c�ci devir,c;). ` ; <br /> � <br /> � f l�l�c:�r�: rirt��dr�wrtsE�c��uis t)r��Ehc^r �dt<liti<i���: Ini�a,; r����atan��:clo�� ln ir�y�:�;r.w�ti lin��-(Itt�lw�r��i� �uy linus,�:� � <br /> r3�tci Ih{ irtst��l(cei d�vic�). 1 undc��-s<<�n�i tl�,il leti,��v�in�a tl��.;��cr�I�n4�e;ti�rn;; cr�:,il��: ,� ���;h �,I Ii���,t�l�rit� � <br /> ���t��3 I ��x.c�pL(h<�at risk � <br /> � <br /> � <br /> � <br /> Sign.•it��r Lr'a.�__�%-� �- .._ Dalc <br />