Certification Renewal By Fax Form
(Please fill out form completely)

Please indicate below what certificate(s) you are renewing:

___ Water  Distribution          Certificate No: ___________    Grade: ____

___ Laboratory Analyst          Certificate No: ___________    Grade: ____

___ Cross-Connection Control   Certificate No: ___________

___ Water Conservation Practitioner    Certificate No: ___________

Certificate No: ___________________________

Requested Exam Date:_____________________

Exam Site:______________________________

 Name: ________________________________

Address: _______________________________

City: _______________ St.______  Zip_______

Telephone No.: __________________________

Yes _______

No ________

Have you changed
yor name?

Yes _______

No ________
If yes, please attach copies of supporting deocuments i.e. certificates, court doucments, etc.

Circle Credit Card Type:          Visa         Master Card       American Express 

 Name of Cardholder:    ___________________________________________

 Credit Card No. _______________________________Exp. Date______

 Total Amount to Charge: _________Signature________________________

Questions?  Call Cheyene Young – Certification Coordinator at
Phone: 909-481-7200 ext. 304  Fax: 909-481-4688.
Address: 10574 Acacia Street, Suite D6, Rancho Cucamonga, CA   91730