NJCPSD Backflow Prevention Form

BACK FLOW PREVENTION - PORTABLE WATER EXPANSION TANK

LETTER OF ACKNOWLEDGEMENT

I, {name}, have been made aware of the need to install a Portable Water Expansion Tank at {addressCity} (address). At this time I decline to install this fixture at your recommendation. I acknowledge that I have been made aware of the possibility of damage to my plumbing facilities as a result of my failure to follow your recommendations.

The Northern Jackson County Public Service District will not be held responsible or liable for any damages incurred due to not installing the recommended Expansion Tank.

FULL NAME:

Email

example@example.com

ADDRESS, CITY, STATE, ZIP:

Owner Signature

Date

Please sign the Letter of Acknowledgement, detach and return to:

Northern Jackson County Public Service District

39 Gilmore Drive, Sandyville, WV 25275