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2. Name:*
4. Mailing Address:*
6. City, State & Zip:*
8. Email:*
10. 1.) Are you currently certified as a Backflow Prevention Assembly Tester by an approved entity such as the American Water Works Association?

    1. Yes (Expiration must be after today)
    2. No (You do not meet the minimum qualifications.
12. 2.) Do you wish to be listed as available for hire to the general public for testing?

    1. Yes
    2. No
14. If yes, what phone number would you like to be listed?
16. 3.) Please provide the following information relative to the test equipment that is at your disposal for Backflow Prevention Assembly Testing. Please be sure to include the following:
    Manufacturer:
    Model:
    Serial Number:
    Calibration Date:*
18. Please list the owner of the Equipment. Include the following:

    Company:
    Contact Person:
    Mailing Address:*

20. Please email backflow certification and test kit calibration to mgentry@ci.patterson.ca.us after submitting the application.  The application cannot be processed without the documents.

22. By printing my name, I certify that all the above information is true:*
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24. Submit Submit and Print

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