Name *

First Name

Last Name

Phone *

(###)

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Service Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pass / Fail Test *

I understand that the backflow test I am signing up for is a pass/fail initial test only and does not include repairs or replacements. I understand that if my assembly fails inspection, Seeger Water will contact me prior to any repairs. Furthermore, I understand that this is a single test for a single assembly - additional assemblies will be invoiced.

Access to Private Property *

I hereby consent to give Seeger Water personnel access to my property for the purpose of performing my backflow prevention assembly test. Seeger Water's personnel understand that we may be recorded or surveilled while on my private property and will conduct themselves in a professional manner.

Residential Test Only *

I understand that I am signing up for a residential backflow test only. This test is to be performed on a single family residence that is occupied by an individual or family. I understand that if I use this form for a commercial backflow test, I will be invoiced at the commercial rate and sales taxes will apply.