Fillable 20_ _ OPU Registered Tester Form (Owatonna Public Utilities)

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20_ _ OPU Registered Tester Form (Owatonna Public Utilities)

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H:\WAT\MISC\BACKFLOW\2007\Registered Tester Form.doc
Date:_____________
208 S Walnut Ave.
P.O. Box 800
Owatonna, Mn 55060
507-451-2480
20_ _ OPU Registered Tester Form
Name:_______________________________________________________
Address:_____________________________________________________
City, State Zip:________________________________________________
Company Name:______________________________________________
Phone: ______________________ Fax: ______________________
Tester ID #:_______________
Are you a licensed plumber? Yes__ No__ License No._______________
Are you a licensed fire protection contractor? Yes__ No__ License No._____________
Are you a licensed sprinkler fitter? Yes__ No__ License No._______________
Test Equipment Used:
Make:______________________ Model:___________________________
Serial #:____________________ Calibration Date:___________________
Signature:_____________________________________________________
By signing this form you are agreeing to follow all of the requirements of OPU’s Cross Connection and Backflow Prevention
Plan and attesting to the accuracy of any test results submitted.
Remarks:_________________________________________________________________
_________________________________________________________________________
______________________________________
Include photo copy of ID card, proof of required training, equipment calibration report, and licensures (if
applicable). Please submit every calendar year.
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20_ _ OPU Registered Tester Form (Owatonna Public Utilities)

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Completed 8 June 2021

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