SEND KIT(S) TO:

ARCO Engineering, Inc.
3317 Gilmore Industrial Blvd.
Louisville, KY 40213
Ph: (502) 966-3134
Fx: (502) 966-3135
sales@arcoengineering.com
BACKFLOW TEST KIT - CERTIFICATION SERVICE REQUEST FORM
CONTACT INFORMATION
Date: .
Name: .
Phone: .

RETURN SHIPPING ADDRESS
Attn. and/or PO#: .
Company: .
Address: .
Address: .
City, State, Zip: .
Return Via (circle): UPS
Ground		 UPS
2nd Day Air		 UPS
Next Day Air		 Other:

KIT(S) RETURNED
BRAND MODEL SERIAL NO. COMMENT
(i.e. additional service required)
. . . .
       
. . . .

CREDIT CARD INFORMATION
Credit Card (circle): American Express          Mastercard          Visa
Security Code:
  
Number: .
Credit Card
Billing Address:
  
Expiration: .
Name on Card: .
Send kit(s) to address at top of form. Certification charge is $100.00 each and includes differential pressure gauge calibration, static gauge calibration or replacement, static pressure check, hose filter check, and certification papers showing accuracy traceable to NIST. If additional service is required we will contact you before proceeding. Your credit card will be charged for service performed plus freight.         Form Rev.: 06/01/07