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Get SC Backflow Device Certification Form

E Company Name Address Phone Number FAX Customer: Type: Size: Make: Model: Serial #: Application: Water Meter #: Account #: Service Address: Billing Address: (if different) Comments: Check No. 1 Test Before Repairs Mark One: Check No. 2 Mark One: Leaked: Leaked: Closed Tight: Closed Tight: Air-Inlet Valve or Relief Valve Opened at lbs. Mark One: Leaked: Leaked: Closed Tight: Closed Tight: Mark One: Diff Press Mark One: #2 Gate or Ball (Check One) Mark One: Mark One: .

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