City-Coordinated Backflow Prevention Assembly Testing Program Form

Residential Customers

Please provide the following information to participate in the City's Coordinated Backflow Assembly Testing Program. The City will coordinate the testing of your backflow assembly by a certified contractor.

An "*" marks a field as required.

Applicant Information

* First Name:

* Last Name:

* Best Daytime Phone Number:

* Additional Phone Number:

* Email Address:

* Home Status:
Owner
Tennant

* Home Street Address:

* City:

* Zip Code:

Location Address of the Backflow Assembly: (if different from above)

I understand that the Contractor, retained by the City to perform the testing of the backflow prevention assembly at the above noted location, is responsible for any damage to my property and that any questions or concerns regarding the testing services should be directed to the Contractor after the test is performed. I have read the information sheet here.

* Signature (click "Save Signature" when done signing)