Backflow Tester Application

Tester Name *

Company Name

BPAT License Number *

Expiration Date * +

Address *

City *

State *

Zip *

Phone Number *

Email Address *

Tester Cell Phone Number

Gage Serial Number *

Calibration Date * +

Model Number *

Calibrated by *

Is company a fire line company? *

Do you wish to be added to the City's Public Tester List? *

Yes

By entering my full name below and clicking Agree, I am providing my electronic signature verifying that the information provided on and with this application is true and correct. Additionally, I agree to comply with all TCEQ and City of Temple regulations regarding cross-connection control as they relate to my role as a backflow prevention assembly tester. *

Agree

Name *

* +

Required Documents (all documents must be legible for registration)

Valid Photo ID *

TCEQ BPAT License *

Certificate of Calibration *