What does the Backflow Prevention Device Annual Test Report record?

It records device and service information, initial and final test results, repairs, pass or fail status, and certified tester details.

Who completes the annual test report?

The form includes fields for certified testers to record test results, repairs, their identifying information, and dates.

Do I need a notary for the Backflow Prevention Device Annual Test Report?

No. The report has fields for certified tester signatures and dates, but no notary block; it identifies no notarized attachment or sworn step.

How do I submit the Backflow Prevention Device Annual Test Report?

Return it to the City of Sebastopol Public Works Department at 714 Johnson Street, Sebastopol, CA 95472.

Sebastopol, CA · Sonoma County

No notary required

Backflow Prevention Device Annual Test Report

Certified testers use this report to record annual backflow prevention device test results and return them to Sebastopol Public Works.

What this form is

This report records annual test results for a backflow prevention device, along with any repairs and final test results. It asks for the service and mailing addresses, account and device information, test readings, repair details, pass or fail status, and certified tester names and dates. The completed report is returned to the City of Sebastopol Public Works Department.

Who needs it

A certified tester completing an annual test of a backflow prevention device uses this report to document and return the results.

How to submit it

Return the annual test report to the City of Sebastopol Public Works Department, 714 Johnson Street, Sebastopol, CA 95472, as shown on the form.

About notarization

This report is signed and dated by certified tester(s) without a notary; it does not identify any notarized attachment or sworn step.

How to submit this form

1
Download The Report
Download the Backflow Prevention Device Annual Test Report.
2
Complete Device Information
Enter the service and mailing addresses, account information, and backflow device details.
3
Record Test Results
Document test readings, any repairs, final results, and the certified tester information and dates.
4
Return The Report
Return the completed report to the City of Sebastopol Public Works Department at the address shown on the form.

Frequently asked questions

What does the Backflow Prevention Device Annual Test Report record?: It records device and service information, initial and final test results, repairs, pass or fail status, and certified tester details.
Who completes the annual test report?: The form includes fields for certified testers to record test results, repairs, their identifying information, and dates.
Do I need a notary for the Backflow Prevention Device Annual Test Report?: No. The report has fields for certified tester signatures and dates, but no notary block; it identifies no notarized attachment or sworn step.
How do I submit the Backflow Prevention Device Annual Test Report?: Return it to the City of Sebastopol Public Works Department at 714 Johnson Street, Sebastopol, CA 95472.

Need something notarized?

This Backflow Prevention Device Annual Test Report doesn’t need a notary — but if you have another Sebastopol form that does, a commissioned online notary can help.