Service Request Form

To schedule an appointment, please complete the form below.

Your Name:

Email Address:

Phone Numer

Are You on a Shut-off Notice?

Type of Location

Business Name

Street Address

City

State Oregon

Zip Code

Water Purveyor

Billing Street Address

Billing City

Billing State

Billing Zip Code

Authorization to Perform Service Yes
No

Location of Device (If Known)

Number of Devices

Your Hours of Operation

Additional Information

After clicking the submit button, wait for the bar to load on the top of the page and then click "continue" to see your order details. We will contact you shortly. Thanks!

This contact form was created by Freedback.

We charge $40.00 for one device and give discounts for multiple devices at the same location. We will take care of all the paperwork, notify the water company and send a copy of the test report and invoice to you once the device has been tested. This usually takes about a week.

Backflow device

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