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Backflow Inspection Report Submission

2. Tester Information

4. First & Last Name*

5. Company Name*

7. Phone Number*

8. Email

10. Backflow Location Information

12. Business Name*

14. Address*

    Physical Address Only

16. Number of Submissions

    Type a number 1 - 5

17. Instructions

    If a business has more than one backflow you may submit up to 5 at a time. If there are multiple businesses, please submit separately.

    If a business has more than one backflow you may submit up to 5 at a time. If there are multiple businesses, please submit separately.

19. File Upload*

    PDF Format is Preferred

21. File 2 Upload

23. File 3 Upload

25. File 4 Upload

27. File 5 Upload

29. Need a backflow form?

    <style> .css { text-align: justify; } a.css { font-weight: bold; } </style> <div class = "css">Feel free to use <a href = "/DocumentCenter/View/274/Backflow-Inspection-Application-PDF" class = "css" target = "_blank">this</a hfref> one. Electronic signatures are accepted. Click <a href= "https://helpx.adobe.com/acrobat/how-to/fill-and-sign-forms-anywhere.html?set=acrobat--fundamentals--pdf-forms" class = "css" target = "_blank">here</a href> for more information about e-signing pdf documents.</div>

    Feel free to use this one. Electronic signatures are accepted. Click here for more information about e-signing pdf documents.

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30. Submit

* indicates a required field