By signing below, I agree to participate in the special contract pricing for annual
backflow testing and acknowledge that the annual testing fee of $21 will be added once
a year to my water bill for the property located at the following address:
________________________________________________ _______________ _
If any repairs are needed the homeowner will be contacted by the tester. In addition,
by signing below I give the contract tester, Carter’s Fire Sprinkler, permission to enter
my property to test the backflow assembly.
I further agree that if I am the property owner, and not the resident, I will notify the
tenant of the backflow testing charge on the water bill, and will be responsible for any
reimbursement to the tenant.
Property Owner Signature Date
Printed Name Contact Phone Number
City of Lebanon
Attn: Backflow Program
925 S. Main Street
Lebanon, OR 97355
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