Backflow Device Certification




If you do not have a back-flow device as pictured below, you must still complete this certification form in its entirety. You cannot be exempted from the program requirements unless you fill out all fields completely. 

Name:

Address:

Mailing Address (if not street address):

Phone:

Cell:

Email:


 This property does not have an installed backflow device pictured below:
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A checkmark in the box indicates a "yes" answer. Please mark the following boxes that pertain to the property listed above:
 Underground irrigation or sprinkler system
 Water powered sump pump
 Swimming pool or spa
 Boiler for home heating (hot water baseboard or radiator heat)
 Water well used on the property for ANY purpose

Please check one of the boxes indicating the material of the water line coming in your house (usually in basement):
 Copper
 Galvanized
 Plastic