Customer Name(Required)

Mailing Address

Address(Required)

Premise Address

Address(Required)

Backflow Prevention Device Information

Please review and make your selections for the backflow assembly and type as appropriate, and include the backflow device details. The backflow prevention device must be approved by USC (University of Southern California). For a list of approved devices, please visit https://fccchr.usc.edu/list.html.

Backflow Assembly(Required)
Backflow Type(Required)

Device Details

Check Valve #1(Required)
Check Valve #2(Required)
Relief Value(Required)
Pass/Fail(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.