4. 

   
   

5. Customer Provided Information – 

   Requested by July 1, 2025

   
   

   This form should be filled out by an individual who is directly involved in working with Qualified Testers/ Specialists for annual backflow prevention assembly (BPA) performance testing, repairs and/or replacements, hazard assessments, or has been appointed as a User Supervisor at one or more locations. A separate form for each site with multiple BPA’s is required. 

   
   

   *See CCCPH section 3.2.2, (f), 1-2 & (g) for more information on User Supervisors and their compliance requirements.

   For questions, please contact the Cross-Connection Specialist at:(408) 586-3348 e-mail backflow@milpitas.gov

7. Are you the User Supervisor?

   1. Yes
   2. No
9. Physical Site / Service Address (where water service is being received)

   Street Number and Name

10. Unit Number
12. City
13. State
14. Zip Code
15. Nearest Cross Street
17. Emergency Contact Information
19. First Name
20. Last Name
22. Phone Number

    Include extension number, if applicable

23. Email Address
25. Mailing Address (Property Owner)
27. First Name
28. Last Name
30. Address

    Street Number and Name

31. Unit Number
33. City
34. State
35. Zip Code
37. Qualified Backflow Prevention Assembly Testing Company 2025-26
    -- Select One --1 Hour Drain4th of July Backflow LLCAble Construction GroupAcco Engineered SystemsAcme Bay Area BackflowAir Systems Inc.All American BackflowAlliance Backflow ServicesAll Pro Backflow, Inc.American Water Heater ServiceA Milpitas Backflow TestingBackflow Prevention Specialists, Inc.Backflow Team, LLCBackflow UnlimitedBay And Valley Backflow ServicesBay Area Backflow IncBayline Plumbing Inc.Burr Plumbing & Pumping, Inc.Cagwin & Dorward Landscape ContractorsCalifornia Backflow ServicesCallan CorpCarrera Backflow SpecialistsCertified Backflow Assembly Testing, LLCChris' Plumbing Inc.Ciari Plumbing & Heating, Inc.City Certified Backflow Prevention, Inc.County of Santa ClaraEnvy PlumbingEvergreen LandscapesFlow City PlumbingFrank Bonetti PlumbingFriendly Fire SystemsGot Backflow?Greater Bay Backflow, LLCHall's PlumbingJackson & Son Plumbing IncJ McCabe Plumbing IncLescure CompanyMaster Plumbing And SewerMilpitas Backflow Prevention ServicesNickell Fire Protection IncParagon MechanicalPeninSula BackFlowQuality BackflowRobertson's BackflowRomero Landscaping & IrrigationSalcido's Backflow ServicesSilicon Valley Home ServicesTgs Backflow ServiceThe Backflow Guy Inc.The Backflow Pro, Inc.The Repair People Ltd.Therma LLCTriton PlumbingUnited Mechanical

    Please select from the dropdown list which qualified testing company was retained.

39. Water Service & Backflow Prevention Assembly (BPA) Information

    See images below for guidance in locating requested information.

41. Location Description

    (example: Behind Water Meter, etc.)

42. 
44. Water Meter Serial Number
45. 
46. 
48. BPA Serial Number
49. BPA Manufacturer
50. BPA Model
51. BPA Type (RP, etc.)
53. BPA Size
55. 
57. END OF FORM.

    If you have multiple Backflow Prevention Assembly devices to add, please submit another form.  If you have trouble submitting this form or need further assistance, please e-mail backflow@milpitas.gov.  Thank you.

Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field