Hunters Creek Village, TX · Harris County
Backflow Prevention Assembly Test and Maintenance Report
Certified backflow testers complete this report to document an assembly test and return it to Memorial Villages Water Authority before continuous water service.
What this form is
This report records the type and details of a backflow prevention assembly, test results, repairs, and the tester’s certification. The form states that assemblies must be tested upon installation and at least annually, and that a completed report must be returned to Memorial Villages Water Authority before continuous water service can be provided. It asks for customer and device information, test results, and tester and firm details.
Who needs it
A Certified Backflow Prevention Device Tester completes and returns this report for a backflow assembly upon installation and at least annually.
How to submit it
Return the completed report to Memorial Villages Water Authority, 8955 Gaylord Drive, Houston, Texas 77024; the form also lists fax (713) 465-8387.
About notarization
The tester signs and dates this report; it has no notary block or notarized attachment.
How to submit this form
- 1
Download The Report
Download the Backflow Prevention Assembly Test and Maintenance Report PDF.
- 2
Complete The Report
Have a Certified Backflow Prevention Device Tester enter the customer, assembly, test, repair, and tester information.
- 3
Review The Report
Check the report details and have the tester certify, sign, and date the form.
- 4
Return It To The Water Authority
Return the report to Memorial Villages Water Authority at the listed address or fax it to the number on the form.
Frequently asked questions
- Do I need a notary for the Backflow Prevention Assembly Test and Maintenance Report?
- No. The tester signs and dates this report; it has no notary block or notarized attachment.
- How do I submit the Backflow Prevention Assembly Test and Maintenance Report?
- Return it to Memorial Villages Water Authority at 8955 Gaylord Drive, Houston, Texas 77024. The form also lists fax (713) 465-8387.
- Who completes this backflow test report?
- The form says it must be completed by a Certified Backflow Prevention Device Tester.
- What information does the report request?
- It asks for customer and service address details, assembly type and identifying information, test results, any repairs and materials used, and tester and firm details.