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 (Optional)

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

Never worry about missing your backflow test again. Our program provides peace of mind that you will always be in compliance.

When you enroll in our Auto Test Program, we will test your backflow device each year automatically for a 3 year period and maintain your testing fee at the same rate for that term. At the end of that term, we will send you a renewal agreement form to be returned to us if you wish to continue in the program. You will receive a reminder card a month prior to when your test is due.

In the event testing is performed and we are not notified of a change in occupancy, you will be responsible for the testing fee.

Enroll me in the Auto Test Program. By checking this box and typing my legal name above I hereby agree to be enroll in the Auto Test Program for a period of three years.

Additional Information/Comments (courtesy call, backyard, locked gate, dogs, etc)

What happens after your request is sent?

Upon completion of the test our service technician will leave a packet on your front door which will include a copy of your test report along with our bill. We will submit all necessary reports to your water provider. Please note, we will not contact you prior to testing unless you request a courtesy call which can be made in the comment section above. Please note, we may not contact you in person prior to testing your device unless requested.

Enter the number shown above

Contact Us

Hempel Backflow Testing LLC
PO Box 20271
Keizer, OR 97307
Phone: 503-390-1961
Email: office@hempelbackflow.com
LCB# 8372 · CCB# 192917

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