Charlotte Backflow | Backflow Preventer Test Request

Customer Name*

Subdivision

Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the service address the same as the billing address?*

YesNo

Billing Address

Phone Number*

E-mail*

I would like to have my invoice MAILED to me.

We e-mail all invoices be default unless you select the option above to receive them by regular USPS mail instead.

Please make sure to whitelist our email address to avoid missing the invoice due to spam filters.

We invoice AFTER work/test has been completed.

Type of Backflow Assembly*

Residential IrrigationCommercial IrrigationDomesticFireline

Type of Backflow_OLD*

Residential IrrigationCommercial IrrigationDomesticFireLine

Service Number, Device ID or CCN listed on letter

City of Charlotte only (Service No), Concord (Device ID) or Kannapolis (CCN)

Device Location(s)*

This is found under location of assembly.

Test Due Date*

MonthDayYear

Optional: Upload a copy of your letter from the city

Does someone need to be on site/home to complete the test?*

YesNoI don't know

Comments

If you desire a copy of the completed test report for your records, PLEASE note that in the comments field. 0/75

How did you hear about/find us?

How would you like to receive your invoice?*

E-mailedMailed Paper Copy

*

I agree that by submitting this service that I will pay all applicable service/materials charges as invoiced and that any verbal authorizations/approvals of work are hereby binding. I consent that if any repair parts are installed in/on my backflow device to achieve a passing result that I will pay reasonable materials and labor costs associated with such repair at tester's discretion, we typically will make repairs at time of test if we have parts on the truck and it will result in less labor costs to the customer to repair at time of test. I also agree to pay per the terms listed on the final invoice and a 1.5% monthly interest (18% per annum) charge on overdue balances and all collection costs incurred. I understand that my passing backflow test report may be held pending final payment.

I understand that my irrigation system backflow will be left the way it was found (Example: if your device is winterized when we arrive, we will put it back the way it was found, we WILL NOT leave the water on) unless I ask otherwise. I also understand that if the water is not on to my backflow preventer that additional charges may apply to turn the water on/off. A backflow test is not a substitution to a Spring Startup service to get the water turned on for the season.