Residential Backflow Testing Agreement Online Form

Customer Name(Required)

First Last

Customer Information(Required)

Owner

Renter

Landlord

Property Manager

Service Address(Required)

Street Address City State ZIP Code

Mailing Address

Same as previous

Street Address City State ZIP Code

Location on Property(Required)

SUB Account Number(Required)

Email(Required)

Home Phone(Required)

Cell Phone

Date(Required)

Message

Customer Consent(Required)

I hereby verify the information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

By hitting submit, I:
*Certify that all information I have provided is true and accurate.
*Authorize SUB to provide my contact information to the program contracted tester.
*Grant SUB permission to schedule and authorize a certified backflow tester to enter the
property listed above to test the backflow prevention assembly.
*Agree to provide access for the purpose of testing the backflow assembly.
*Choose to voluntarily enter into SUB’s backflow assembly testing program
*Agree to pay a $29.00 per assembly testing fee that will be included on my SUB
statement upon completion of assembly testing.
*Understand that any backflow assembly repair or replacement will need to be scheduled
by me and are separate costs that are not included in the testing fee.
*Understand that I will remain on the program until either, I contact SUB to remove
myself or I move.
*Understand that SUB has the right to remove me from the program at their discretion

Customer Electronic Signature (Type Your Full Name)(Required)

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