Shallowater, TX · Lubbock County
Backflow Prevention Assembly Test and Maintenance Report
This report records backflow assembly test and maintenance results and is completed by the licensed tester for each assembly tested.
What this form is
The report documents the results of testing and maintaining a backflow prevention assembly. The form says one must be completed for each assembly tested, and the signed, dated original must be provided to the public water supplier for recordkeeping. It asks for public water system and service address information, assembly details, test results, gauge information, repair details when applicable, and the licensed tester’s information and signature.
Who needs it
A licensed tester completes this report for each backflow prevention assembly tested and provides the signed original to the public water supplier.
How to submit it
The licensed tester must print and sign the report unless TCEQ-approved electronic recordkeeping is used. Provide the hardcopy original to the Public Water System at PO Box 246, Shallowater, TX 79363.
About notarization
This report is signed and dated by the licensed tester without a notary; it identifies no notarized or sworn attachment, so the tester simply signs and dates it.
How to submit this form
- 1
Download The Report
Download the Backflow Prevention Assembly Test and Maintenance Report PDF.
- 2
Complete The Report
Complete one report for each assembly tested, recording the assembly, test results, gauge, and licensed tester information.
- 3
Review And Sign
The licensed tester signs and dates the report; print it unless TCEQ-approved electronic recordkeeping is in use.
- 4
Submit The Original
Provide the hardcopy original and all report pages to the Public Water System at PO Box 246, Shallowater, TX 79363.
Frequently asked questions
- What does the Backflow Prevention Assembly Test and Maintenance Report record?
- It documents test and maintenance results for a backflow prevention assembly, along with assembly details, gauge information, any repairs, and the licensed tester’s information.
- Who completes the backflow test report?
- A licensed tester completes one report for each assembly tested. Follow-up testing by a different tester must be documented on a separate form.
- Do I need a notary for the Backflow Prevention Assembly Test and Maintenance Report?
- No. The licensed tester signs and dates the report; the document does not identify a notarized or sworn attachment.
- How do I submit the backflow test report?
- Provide the signed, dated hardcopy original to the Public Water System at PO Box 246, Shallowater, TX 79363. All pages of the report must be submitted.