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.

All sections of the form must be completed.
Personal Information:
Name

First NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Business Information:
Business Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
ID#
Date Issued

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of years as a backflow tester:
Do you want your information (name, phone number, and email) listed on our website 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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Do you want your information (name, phone and email) to be listed on our website as a backflow tester?
Should be Empty:

NNEPA Public Water System Supervision Program

REGISTRATION FORM FOR CERTIFIED BACKFLOW ASSEMBLY TESTER

Personal Information:

Business Information:

Certification Information: