Request a Test

If you have received a shut-off notice OR to schedule a New Install Testing, please do not use this form. Call us directly at 503-390-1961.

Check the box if you are a new customer	I am a new customer
Name
E-mail
Company Name
Telephone
Test Address
Test City
Test State
Test Zip
Billing Address (if different)
Billing City
Billing State
Billing Zip
Property Type
Month Test is Due
Water Purveyor
Location of Device on Property (if new customer)
Auto-Test Program When you enroll in the Auto Test Program, we will test your backflow device automatically and report the results to your water purveyor each year. This program provides peace of mind that you will always be in compliance
Enroll in Auto-Test Program When you check this box, you will be sent an agreement form giving us permission to test your device every year. After we receive your signed form, you will then be enrolled in the Auto Test Program. You will receive a reminder card the month prior to when your test is due. Please Note: The auto-test agreement is not available online. Completing the above test request does not complete the enrollment for the auto-test program. Enrollment is not complete until we receive your signed auto-test agreement by email or mail. Enroll in Auto-Test Program/Request the Agreement Form
Additional Information/Comments
What happens after your request is sent? Upon completion of the test our service tech will leave a door hanger on your door which will include a copy of the test results along with the bill for the test and any necessary repairs. We will submit all necessary reports to your water provider. Please note, we may not contact you in person prior to testing your device unless requested.
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Contact Us

Hempel Backflow Testing LLC
PO Box 20271
Keizer, OR 97307
Phone: 503-390-1961
Fax: 503-463-1485
Email: tom@testsbytom.com
LSB# 8372 · CCB# 192917

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Request a Test

Auto-Test Program

What happens after your request is sent?

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