Winters, CA · Yolo County
Backflow Test Form
Water customers and backflow testers use this form to record assembly details, test results, repairs, and the tester’s signature for a City of Winters water service location.
What this form is
This form records information about a backflow prevention assembly, its water service location, and the results of an initial test and any test after repair. It asks for customer and assembly details, service type, test readings, repair information, dates, comments, and the tester’s identifying information and signature. If the assembly fails, the form directs the tester to email the test report and notify Public Works within 24 hours.
Who needs it
A water customer or backflow tester completing a test for an assembly at a City of Winters water service location needs this form.
How to submit it
Email a copy to [email protected]; if the assembly fails, email the test report and notify City of Winters Public Works within 24 hours.
About notarization
This form is signed without a notary; it has no notarized attachment or sworn step, and the tester signs and dates the test report.
How to submit this form
- 1
Download The Form
Download the Backflow Test Form for a City of Winters water service location.
- 2
Complete Customer And Assembly Details
Fill in the water customer, service location, assembly, and water purveyor information requested.
- 3
Record Test Results
Enter test readings, repair information if applicable, comments, dates, and the tester’s information and signature.
- 4
Email A Copy
Email a copy to [email protected]. If the assembly fails, email the test report and notify Public Works within 24 hours.
Frequently asked questions
- What does the Backflow Test Form record?
- It records water customer and assembly information, service location, test readings, repair details, comments, dates, and the backflow tester’s information and signature.
- Who completes the Backflow Test Form?
- A backflow tester completes the assembly and test information for a device at a City of Winters water service location.
- How do I submit the Backflow Test Form?
- Email a copy to [email protected]. If the assembly fails, email the test report and notify City of Winters Public Works within 24 hours.
- Do I need a notary for the Backflow Test Form?
- No. This form is signed without a notary, and it has no notarized attachment or sworn step; the tester signs and dates the test report.