Are you a backflow tester? If so, it's important that you register with the City of Edmonton. Required registration helps ensure that backflow testers are kept up to date on changes and safety requirements. Registration is free, and takes just minutes to complete online. Click the link below to get started!
| Question | Answer |
|---|---|
| Form Name | Backflow Tester Registration Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dallas backflow registration, city of dallas backflow contractor, backflow license dallas, coppell tx backflow tester registration |
BACKFLOW ASSEMBLY TESTER
REGISTRATION
NEW RENEWAL
Contractor #
MUST BE COMPLETELY FILLED OUT IN ORDER TO BE ACCEPTED FOR REGISTRATION
ORIGINAL REGISTRATION: The licensed Tester must personally appear at 320 E. Jefferson Room 105 and furnish (1) This original form completed, (2) Their Current Backflow Tester’s pocket license, (3) An approved photo identification, (4) Payment of $120.00. Please make checks payable to “City of Dallas”.
RENEWAL REGISTRATIONS: May be processed in person at any Building Inspections office or
(1)All documents listed above are required for each registration renewal, (2) If not registering in person, this document must be notarized, (3) Payment of $120.00. Please make checks payable to “City of Dallas”.
Please note: Backflow Tester Certificates of Registration provided for in the code, expire annually upon the expiration date of the State License. Pursuant to the City Code, application is hereby made for registration as a Backflow Tester Contractor.
All Information Must Be Complete (Please Do Not Use Same)
Backflow Tester Information
Date __ / __ / |
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State License# |
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Expiration Date:_____ /__ _ /______ |
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Name of Tester: |
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If company is located within the city limits of Dallas, please provide the certificate of occupancy number:
C.O. #
The Licensed Backflow Tester is the only person authorized to sign permits or validations to perform backflow test.
Name |
PIN # (LIMIT TO 4 DIGITS OR LESS) |
(TESTER)
I DO DEPOSE AND SAY THE ABOVE INFORMATION IS TRUE AND CORRECT.
SIGNED X
Signature of Responsible License Holder
Registration Clerk/Notary Public: |
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(Must Be Signed by Registration Clerk or Notarized) |
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Sworn to me before this |
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Any changes or corrections to this information must be submitted on this
same form and marked as amended. A $30.00 record change fee shall apply.
Revised: 09/30/2015