Kyle, TX · Hays County
Backflow Prevention Assembly Test and Maintenance Report
Licensed testers use this report to document backflow prevention assembly testing and maintenance and provide the signed original to the public water system.
What this form is
The report records test results and maintenance for each backflow prevention assembly tested. It asks for public water system and service address details, assembly and gauge information, test results, repairs, and licensed tester details. The instructions say to complete it on-site during testing and provide the signed, dated original to the public water supplier for recordkeeping.
Who needs it
A licensed tester who tests or maintains a backflow prevention assembly completes a separate report for each assembly tested.
How to submit it
Provide the signed hardcopy original to the Public Water System for recordkeeping, and submit all pages of the report to the water system.
About notarization
The licensed tester signs and dates this report without a notary; the document does not mention any notarized or sworn attachment.
How to submit this form
- 1
Download The Report
Download the Backflow Prevention Assembly Test and Maintenance Report.
- 2
Complete It During Testing
Complete the report on-site while testing the assembly, by hand or electronically.
- 3
Record Test And Tester Details
Enter assembly, gauge, test result, repair, and licensed tester information; use a separate form for each assembly tested.
- 4
Sign And Submit
The licensed tester signs and dates the report. Provide the signed original and all pages to the Public Water System.
Frequently asked questions
- What is the Backflow Prevention Assembly Test and Maintenance Report?
- It documents testing and maintenance for a backflow prevention assembly, including test results, repairs, gauge information, and licensed tester details.
- Who completes this report?
- The licensed tester who performs the work completes the report. The instructions require a separate form for each assembly tested and for follow-up testing by a different tester.
- Do I need a notary for the Backflow Prevention Assembly Test and Maintenance Report?
- No. The licensed tester signs and dates the report; it does not mention any notarized or sworn attachment.
- How do I submit the Backflow Prevention Assembly Test and Maintenance Report?
- Provide the signed, dated hardcopy original to the Public Water System for recordkeeping and submit all pages to the water system. Approved electronic recordkeeping is an exception to the hardcopy requirement.
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.