San Benito, TX · Cameron County
Backflow Test and Maintenance Report Form
Licensed testers complete this report for each backflow prevention assembly tested and submit the signed, dated original to San Benito’s public water supplier.
What this form is
This report records test results and maintenance details for each backflow prevention assembly tested. The form directs the tester to submit a signed and dated original to the public water supplier for recordkeeping. It asks for the service address, assembly type and details, test results, repairs, gauge information, and licensed tester and company details.
Who needs it
Licensed testers completing a test of a backflow prevention assembly submit one report for each assembly tested.
How to submit it
Submit the signed and dated original to the public water supplier at 400 N Travis, San Benito, TX 78586, as directed on the form.
About notarization
This document is signed and dated without a notary; the form requires no notarized or sworn attachment, so the licensed tester just signs and dates it.
How to submit this form
- 1
Download The Report
Download the Backflow Test and Maintenance Report Form.
- 2
Complete The Test Details
Complete a separate report for each assembly tested, including the test results and requested assembly, repair, and tester information.
- 3
Sign And Date The Report
The licensed tester signs and dates the report; the form requires no notarization.
- 4
Submit The Original
Send the signed and dated original to the public water supplier at 400 N Travis, San Benito, TX 78586.
Frequently asked questions
- What is the Backflow Test and Maintenance Report for?
- It records test results, maintenance, repairs, and assembly and tester details for each backflow prevention assembly tested.
- Who completes this report?
- A licensed tester completes the report for each assembly tested. The form asks for the tester’s name, signature, company details, and license information.
- How do I submit the Backflow Test and Maintenance Report?
- Submit a signed and dated original to the public water supplier at 400 N Travis, San Benito, TX 78586, as stated on the form.
- Do I need a notary for the Backflow Test and Maintenance Report?
- No. The form does not require notarization or a sworn attachment; the licensed tester signs and dates the report.
Need something notarized?
This Backflow Test and Maintenance Report Form doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.