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Get NY Backflow Preventer Exemption 2008-2024

________________________________ PE/RA or Plumber's Name: ______________________________________ License Number: (if not on letterhead) ______________________________________ Address ______________________________________ Owner's Phone Number Phone Number: (if not on letterhead) PE/RA or LMP Seal & Signature ______________________________________ Owner's Signature NOTE: Where we show (bracketed italicized items), you must use the one appropriate for your facility. Revised 05/29/2008 .

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