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* indicates a required field

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


30. Submit