Request to Re-Issue BPAT #

I have previously held a Texas Backflow Prevention Assembly Tester License.
I have successfully completed the requirements to be re-licensed.
I request TCEQ to re-issue my former BPAT license number.

Name: Date:
City: State: Zip:
Home #: Work #:
Cell #: Fax #:
Previous Texas BPAT License #:

Date BPAT Exam Successfully Completed: