Onondaga County, NY · Onondaga County
Report on Test and Maintenance of Backflow Prevention Device
Certified testers use this form to report a backflow prevention device’s test results and maintenance to the water supplier and health department.
At a glance
- Issued by
- City of Onondaga County · Onondaga County, Onondaga County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- onondaga.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use a separate report for each backflow prevention device. A certified tester completes Part A for an initial or annual test, recording device details, test results, repairs, and certifications; for initial tests, Part B is completed by the design engineer, architect, or water supplier. The form instructs recipients to send copies to the designated health department representative and water supplier within 30 days of testing.
Who needs it
Certified testers report each device’s test and maintenance, with Part B completed for initial tests by a design engineer, architect, or water supplier.
How to submit it
Send one completed copy to the designated health department representative and one to the water supplier within 30 days of testing. The instructions also call for copies to the customer and state or local health department.
About notarization
This report is signed and dated without a notary; the tester and owner or agent certify the test, and the form does not require a notarized attachment.
How to submit this form
- 1
Download the Report
Download the form and use a separate copy for each backflow prevention device.
- 2
Complete Part A
Have a certified tester record the test year, device information, test results, repairs, and required certifications.
- 3
Complete Part B If Needed
For an initial test, have the design engineer, architect, or water supplier complete Part B.
- 4
Send the Copies
Send copies to the designated health department representative and water supplier within 30 days of testing.
Frequently asked questions
- Do I need a notary for the backflow prevention device report?
- No. The tester and property owner or agent sign the report without a notary; the form does not require a notarized attachment.
- How do I submit the backflow prevention device report?
- Send one completed copy to the designated health department representative and one to the water supplier within 30 days of testing. The instructions also call for copies to the customer and state or local health department.
- Who completes Part A of the report?
- A certified tester completes Part A for each device, recording its details, test results, any repairs, and the required certifications.
- When is Part B completed?
- For initial tests only, the design engineer, architect, or water supplier completes Part B to certify that installation follows the approved plans.