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2. Name:*
3. Date:*
   Date:
5. Mailing Address:*
7. City:*
8. State:*
9. Zip Code:*
11. Telephone Daytime:*
12. Telephone Evening:
14. Current Employer:*
16. Mailing Address:*
18. City:*
19. State:*
20. Zip Code:*
22. Telephone:*
23. Fax:
25. Cell Phone:
26. Email:*
28. B.O.L./B.A.T. No.:*
29. Expiration Date:*
    Expiration Date:
30. Backflow Assembly Tester Recertification Date:*
    Backflow Assembly Tester Recertification Date:
    (*Mandatory every two years)
32. Test Equipment Manufacturer:*
33. Model:*
34. Serial Number:*
36. Test Equipment Verification of Calibration Date:*
    Test Equipment Verification of Calibration Date:
    (*Mandatory annually)
38. NOTE: The City of Lewiston has your permission to distribute as well as post your company, employees, and telephone number on the City's web page, available to the general public. Please check one:*

    1. Yes
    2. No
40. **Note: Copies of an annual report verifying test equipment calibration must accompany this application.***
42. **NOTE: The City of Lewiston requires both a backflow assembly test report be submitted to the Water Division within fifteen (15) business days of a test, and a "TAG" containing the tester's name and date of satisfactory test be attached to the assembly. Any backflow prevention assembly left in a failed (non-passing) condition, creating a potential threat to the potable water supply, must be reported to the Water Division within two (2) business days. Registered testers can submit reports online at https://lewiston.tokaytest.com. Only new installation test reports will be accepted via email, fax, or US mail.
44. Do you plan to test backflow assemblies for a Fire Protection company?*

    1. Yes
    2. No
46. If you plan on testing backflow assemblies for a Fire Protection company(s), please list the company name and the Idaho Fire Protection Contractor License number.

    If you answered "Yes" to the above question, please complete this section. If you answered "No", this section does not apply. 

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field