Whitesboro, TX · Grayson County
Backflow Prevention Assembly Test and Maintenance Report
Licensed testers use this report to document backflow prevention assembly test results and provide a signed original to the public water supplier.
What this form is
Complete one report for each backflow prevention assembly tested, documenting assembly details, test results, gauge information, and any repairs. The form is intended to be completed on-site during testing, and the licensed tester who performed the work must sign it unless approved electronic recordkeeping is in use. The signed and dated original must be provided to the public water supplier for recordkeeping.
Who needs it
A licensed tester who tests a backflow prevention assembly completes and signs this report for the public water supplier.
How to submit it
Provide the signed and dated hardcopy original to the public water supplier for recordkeeping. Submit all pages of the report to the water system.
About notarization
This report is signed and dated without a notary; the licensed tester signs to certify the report, and no notarized attachment or related step is specified.
How to submit this form
- 1
Download The Report
Download the Backflow Prevention Assembly Test and Maintenance Report PDF.
- 2
Complete The Report On-Site
Complete one report for each assembly tested, recording assembly details and test results while testing is occurring.
- 3
Record Repairs And Gauge Details
Include applicable repair and gauge information; complete all pages if the remarks section expands.
- 4
Sign And Submit
The licensed tester signs and dates the report. Provide the hardcopy original and all pages to the public water supplier.
Frequently asked questions
- What is the Backflow Prevention Assembly Test and Maintenance Report?
- It documents test and maintenance results for a backflow prevention assembly. The report records assembly details, test results, gauge information, and any repairs.
- Who completes this report?
- The licensed tester who performs the work completes the report. The instructions say testing completed by a licensed tester must be documented on one form.
- How do I submit the report?
- Provide the signed and dated hardcopy original to the public water supplier for recordkeeping. Submit all pages of the report to the water system.
- Do I need a notary for this report?
- No. The licensed tester signs and dates the report; it has no notary block and specifies no notarized attachment or related step.
Need something notarized?
This Backflow Prevention Assembly Test and Maintenance Report doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.