Gold Plan Subscription Application

Tualatin Valley Water District (TVWD) offers its Gold Plan subscription based annual backflow testing program. A $35 fee will be assessed, once annually, to the water bill associated with the service address. Only named individuals on the account my subscribe to the Gold Plan for the service address.

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Return to Gold Plan Subscription for Residential Customers

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Customer Information

Last Name: *

First Name: *

Service Address: *

Address where water service is being provided.

Primary Phone Number: *

Alternate Phone Number:

Email Address: *

Backflow Assembly Information

Location on Property [Optional if known]:

Make:

Model:

Serial Number:

Size:

Acknowledgement *

I agree to the terms of the Gold Plan

I certify the information I have provided is true and correct. I grant Tualatin Valley Water District permission to schedule and authorize a certified backflow tester to enter the property listed above to test the backflow prevention assembly to assure program requirements have been met. By clicking on the acknowledgement button, I choose to voluntarily enter into this TVWD backflow assembly testing program which I understand will include a $35 fee (per assembly) to be added to my water bill. I also understand that if the repair cost of my assembly exceeds $50 it is my responsibility to pay for any additional repairs when repaired by a TVWD contractor. I understand the terms of this agreement will continue until I contact TVWD to remove myself from the program or when I discontinue service at the address listed. TVWD has the right to remove me from the testing program at their discretion. My name is listed on the account for the water service at this address.

Gold Plan Subscription Application

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