Jersey Village, TX · Harris County
Backflow Prevention Assembly
Property owners and certified testers use this form to record backflow assembly details, test results, repairs, and replacement information for submission to the public water supplier.
What this form is
This form records the property and assembly details, initial and post-repair test results, tester and gauge information, repairs, and whether the assembly is a replacement. It states that a form must be completed for each assembly tested and that a signed, dated original must be submitted to the public water supplier for record keeping. The form certifies that the assembly was tested and maintained as required by TCEQ regulations.
Who needs it
Property owners and certified testers use this form to document each backflow prevention assembly tested and provide the results to the public water supplier.
How to submit it
The form says to submit a signed and dated original to the public water supplier for record keeping. It lists Development Division, 3300 Corinth Parkway, Corinth, TX 76208, and fax 940-498-3267.
About notarization
No notary is required; the form calls for the tester’s signature and a signed, dated original, with no notarized attachment or sworn step identified.
How to submit this form
- 1
Download The Form
Download the Backflow Prevention Assembly form.
- 2
Complete The Assembly Details
Enter the property owner and assembly information, including the assembly type, location, make, model, and reason for installation.
- 3
Record Test Results
Complete the applicable test sections and provide tester, gauge, repair, and replacement information.
- 4
Sign And Submit
Have the tester sign and submit the signed, dated original to the public water supplier for record keeping.
Frequently asked questions
- What information does the Backflow Prevention Assembly form collect?
- It asks for property owner and assembly details, test results, tester and gauge information, repairs and materials used, service restoration, and whether the device is a replacement.
- Who completes a Backflow Prevention Assembly form?
- The form includes fields for property and assembly information, test results, and the certified tester’s information and signature. It says a form must be completed for each assembly tested.
- Do I need a notary for the Backflow Prevention Assembly form?
- No. The form calls for the tester’s signature and a signed, dated original; it identifies no notarized attachment or sworn step.
- How do I submit the Backflow Prevention Assembly form?
- Submit a signed and dated original to the public water supplier for record keeping. The form lists Development Division, 3300 Corinth Parkway, Corinth, TX 76208, and fax 940-498-3267.