Backflow Tester Registration Form

NNEPA Public Water System Supervision Program
P.O. Box 339
Window Rock, Arizona 86515
Phone#: (928) 871-7755 Fax#: (928) 871-7818
http://www.navajopublicwater.org
REGISTRATION FORM FOR CERTIFIED BACKFLOW ASSEMBLY TESTER
The Public Water Systems Supervision Program (PWSSP) maintains a roster of the registered certified backflow assembly testers and makes it available to the public. Only registered certified backflow assembly testers are allowed to test assemblies within the jurisdictions of the Navajo Nation. The PWSSP keeps track of all testers and their testing credentials and hold them accountable for their tests. The PWSSP informs tester(s) of any new regulations affecting them or any training opportunity on the Navajo Nation.
Personal Information:
Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Business Information:
Business Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Fax Number
Please enter a valid phone number.
Website:
Certification Information:
Issuing Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
ID#*
Date Issued*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Number of years as a backflow tester:*
All applicants are subject to fees determined by the Director as specified below. The fees are set at the discretion of the Director and may be increased at any time.
Number of Backflow Tester Registration Fees - $25 each x 6% Navajo Nation Sales Tax*
Fee Rate
Fees
Tax Rate
Tax
Total Fees Due
All information reported above is true and correct to the best of my knowledge. I understand this information is subject to verification and any misrepresentative of facts may result in the denial of my backflow tester request.
Type Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Please attach the following:
Photocopy of your current backflow certificate ID card*

Cancelof
Resume*

Cancelof
Backflow Tester Application*

Cancelof
A Navajo Nation EPA-PWSSP Backflow ID will be issued for identification purposes. Please print a copy of this form to send in with your payment and for your record(s). If you have any questions regarding the backflow assembly tester registration request, please contact us at (929) 871-7755.
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NNEPA Public Water System Supervision Program

REGISTRATION FORM FOR CERTIFIED BACKFLOW ASSEMBLY TESTER

Personal Information:

Business Information:

Certification Information: