Request For Backflow Test

PLEASE FILL OUT THIS FORM AND FAX TEST REPORTS ASSOCIATED WITH IT TO:
(813) 746-0940

You also have the option of printing this form and faxing it along with test reports if you so choose.

PRINT FORM

Olin Plumbing, Inc. CFC142800 BF 3752
2123 South 86th Street
Tampa, FL 33619
(813) 246-4401
(813) 443-5820
Fax: (813) 746-0940
Email: olinplumbing@tampabay.rr.com

*If there are different addresses for devices to be tested,
please complete this form separately for each address.

By completing this form you agree to the following:

I understand and acknowledge that typing my name in the Signature field below is the equivalent of physically signing my name to the form and I thereby authorize Olin Plumbing, Inc. to perform the backflow test.

I authorize Olin Plumbing, Inc. to test backflow devices at the stated location.

I understand the water needs to be turned off when devices are being tested and will not hold Olin Plumbing, Inc. responsible for any damages or inconveniencies that may occur due to the water being or not being turned off.

I understand that there may be an additional charge for devices that cannot be easily accessed or devices that require additional time to locate.

I understand that the backflow devices are mechanical and will not hold Olin Plumbing, Inc. responsible for devices that do not recover from test.

I understand and agree to pay Olin Plumbing, Inc. $25 for each backflow test report filed with the City or County. Regardless of whether the backflow device passes or fails the required test or whether or not the device has been removed or cannot be found.

I understand and agree to pay the balance upon receipt and if payment is not made for the test and/or repairs within 7 days, I agree to pay all expenses and fees that Olin Plumbing, Inc. incurs to collect moneys owed. This includes office supplies, labor, postage, lien fees, attorney fees and court costs unless other arrangements have been made.

Fields marked with are required!