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Cross Connection Control Registered Technician Information

  1. Mailing address

  2. Information listed above will not be published or distributed. It is only for contact if the information below is no longer valid.

  3. Current Technician Certification

  4. Type

  5. Type

  6. Type

  7. Do you wish to be on the distributed list?

  8. Are you a licensed plumber?

  9. Are you a registered backflow prevention contractor by the Colorado Division of Fire Safety?

  10. Please attach copies of the following:

  11. It is the responsibility of the technician to keep the required information current in order to remain on the list of registered testers.

  12. I hereby certify that I thoroughly understand the procedures to which I shall comply as a registered cross connection control technician in the Town of Castle Rock.

  13. I agree to the listing of my name and company information on the Town of Castle Rock website or distribution in printed form unless noted above.

  14. I understand that the Town of Castle Rock can remove me from this list at any time.

  15. Please print this form, sign and submit with all applicable copies of documents.

  16. Leave This Blank: