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Backflow Testing Online Request Form

Backflow services offered by Chicago Backflow.

Our backflow testing online request form!

Professional affiliations we have joined.

Links to backflow industry organizations and companies.

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

We accept

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 *.

Invoice To:

Company Name :	If residential, enter RESIDENCE. *
P.O. Number:
E-mail:
Address Line 1:	Please enter billing address.*
Address Line 2:
City:	Please enter billing city.*
State:	Please enter billing state.*
Zip Code:	Please enter billing zip code.*
Contact Name:	Please enter billing contact.*
Phone:	Please enter billing phone.*
Fax:
Requested Test Date:

Job Site:

Job Name:	Please enter site name.*
Address Line 1:	Please enter site address. *
Address Line 2:
City:	Please enter site city.*
State:	Please enter site state. *
Zip Code:
Site Contact Name:
Phone:

Backflow Preventer Device Information:

	Manufacturer	Size	Model #	Serial #	Location of Device
1
2
3
4

Has service been flushed?	Yes No

Directions & Comments:

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

Backflow Testing Online Request Form

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

Member since 1995.

© 1997 - 2009, Chicago Backflow, Inc.

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