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 Chicago Backflow, Inc.
 12607 S. Laramie Ave.
 Alsip, IL 60803
 Phone: 708.389.5600
 Fax:      708.389.5632
 contact@backflow.com

We accept    

Member, Better Business Bureau since 1995
Member since 1995.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
Chicago Backflow invites you to use this form to request backflow testing online of any of your job sites in Illinois, Indiana, Michigan or Mississippi.  All required fields are indicated by an *.  After you click the Send form to CBI button, you will see a confirmation screen which will contain ALL the information you filled-in.  You may print that page for your records.
                              -------- Invoice To --------

Company Name:*
P.O. Number:*
E-Mail:
Address Line one:*
Address Line two:
City:*
State:*
Zip Code:*
Contact Name:*
Phone:*
Fax:*
Order date:
Request test date:

                               --------- Job Site ---------

Job Name:*
Address Line one:*
Address Line two:
City:*
State: *
Zip Code:
Site Contact person:
Phone:

         -- Backflow Preventer Device Information --

Manufacturer Size Model Serial No. Location of Device
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Has service been flushed?  YesNo
Directions
      and Comments:

        

Thanks for the opportunity to serve you.
                                              -Chicago Backflow, Inc.
 
© 1997 - 2008, Chicago Backflow, Inc.