Yadkinville, NC · Yadkin County
Backflow Test and Maintenance Form
Customers and certified testers use this form to record a backflow assembly’s test results, maintenance, repairs, and certification.
What this form is
This form records the location and type of a backflow assembly, customer details, test readings, maintenance, repairs, and the certified tester’s results and signature. It is used to document testing and maintenance of the assembly. The form states that all repairs must be completed within 30 days or at the discretion of the Public Works Director.
Who needs it
Customers and certified testers completing a backflow assembly test or maintenance record can use this form to document the assembly’s condition and results.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the certified tester signs and dates the test record.
How to submit this form
- 1
Download The Form
Download the Backflow Test and Maintenance Form.
- 2
Complete The Test Record
Enter customer and assembly details, test readings, maintenance and repair information, and tester certification details.
- 3
Sign And Date
The certified tester signs and dates the test record.
- 4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Backflow Test and Maintenance Form?
- No. The form has a signature for the tester but no notary block; the certified tester signs and dates the test record.
- How do I submit the Backflow Test and Maintenance Form?
- Submit it to the city department named on the form; check the city website for current contact details.
- What information does the form request?
- It requests customer and assembly details, test readings, maintenance and repair information, certified tester details, and a tester signature.
- When must repairs be completed?
- The form states that all repairs must be completed within 30 days or at the discretion of the Public Works Director.