San Angelo, TX · Tom Green County
Backflow Prevention Assembly Test and Maintenance Report
Licensed testers use this report to document backflow prevention assembly test results and maintenance for submission to the public water supplier.
What this form is
This report records the results of testing and maintaining a backflow prevention assembly, along with assembly details, test readings, gauge information, and the licensed tester’s certification. Complete one report for each assembly tested, on-site while testing occurs. The tester must provide a signed and dated original to the public water supplier for recordkeeping; all pages must be submitted.
Who needs it
A licensed tester who tests a backflow prevention assembly completes and submits this report to the public water supplier.
How to submit it
Provide the signed and dated original to the public water supplier; submit all pages of the report. The form lists the City of San Angelo at 301 W. Beauregard, San Angelo, Texas 76903.
About notarization
This report is signed and dated by the licensed tester without a notary; it has no notarized or sworn attachment, so the tester just signs and dates it.
How to submit this form
- 1
Download The Report
Download the Backflow Prevention Assembly Test and Maintenance Report.
- 2
Complete It During Testing
Complete one report for each assembly tested, on-site while testing occurs.
- 3
Record Test Details
Enter assembly, test, gauge, and licensed tester information; include all pages if remarks extend the report.
- 4
Sign And Submit
The licensed tester signs and dates the report, then provides the original and all pages to the public water supplier.
Frequently asked questions
- What is the Backflow Prevention Assembly Test and Maintenance Report?
- It documents testing and maintenance results for a backflow prevention assembly, including assembly details, test readings, gauge information, and the licensed tester’s certification.
- Who completes this report?
- A licensed tester completes a separate report for each assembly tested. Testing by a different tester during follow-up must be documented on a separate form.
- How do I submit the report?
- Provide the signed and dated original to the public water supplier for recordkeeping. Submit all pages, including any additional pages used for remarks.
- Do I need a notary for this report?
- No. The licensed tester signs and dates the report; it contains no notarized or sworn attachment.
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.