What is a Backflow Testing Form?

A Backflow Testing Form documents test readings, device identification, and tester credentials to confirm the assembly is preventing contaminants entering the potable water supply.

Who may sign the form?

A licensed tester or certified plumber must sign and provide their license or certification number; owners may attest but technician certification is typically required for acceptance.

Can this form be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act and UETA where applicable, provided intent and retention requirements are met and any local notarization rules are observed.

What if the device fails the test?

Document failures and corrective actions on the form, complete repairs, and perform a retest. Submit the failure notice and subsequent passing certification per local authority instructions.

How long should I keep completed forms?

Retain records per local rules; commonly keep them for at least 3–6 years to satisfy audit, insurance, and municipal requirements.

Where do I submit the completed form?

Submit to the local water utility or cross-connection control office via their portal or email address; if unclear, contact the water authority for the accepted submission method.

Backflow Testing Form

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Backflow Testing Services Agreement and Report

Recitals

WHEREAS Client Name: (the "Client") is the owner or authorized agent of the premises where backflow prevention assemblies are installed; and

WHEREAS Service Provider: (the "Service Provider") is duly licensed and qualified to perform backflow assembly testing, maintenance and repairs; and

WHEREAS the parties wish to set forth the terms for testing, reporting and any necessary repairs of backflow prevention assemblies at the Property described below.

Scope of Work

Property & Contact Information

Client Contact Name Client Contact Phone / Email Property Address Service Request Date

Requested on:

Device Information & Test Results

Use this section to document each backflow prevention assembly tested. Attach additional pages if more assemblies are present.

Assembly 1

Assembly Location on Property

Assembly Type: Reduced Pressure (RP) Double Check (DC) Pressure Vacuum Breaker (PVB)

Assembly Size Serial Number / Model Test Date

Initial Upstream Pressure (psi) Differential Pressure Observed (psi)

Relief Valve Operated: Yes No Pass: Pass Fail:

Comments / Observations

Assembly 2 (if applicable)

Assembly Location on Property

Assembly Type: Reduced Pressure (RP) Double Check (DC) Pressure Vacuum Breaker (PVB)

Assembly Size Serial Number / Model Test Date

Initial Upstream Pressure (psi) Differential Pressure Observed (psi)

Relief Valve Operated: Yes No Pass: Pass Fail:

Comments / Observations

Repairs, Parts & Recommendations

Repairs Performed / Parts Replaced Recommended Corrective Actions / Next Test Due

Inspector / Technician

Inspector / Technician Name License / Certification Number

Payment Terms

Total Fee for Services: $

Payment Schedule:

Late Payment Fee:

Term and Termination

Agreement Commencement Date:

Agreement Termination Date:

Either party may terminate this Agreement for cause upon written notice to the other party specifying the breach and providing a day cure period. Termination shall not relieve Client of payment obligations for services rendered and parts supplied prior to termination.

Confidentiality

Each party shall keep confidential and shall not disclose to third parties non-public business information obtained in connection with this Agreement, including test data, repair invoices and pricing, except as required by law or for the performance of the services under this Agreement. Confidential information shall be used solely for the purposes of performing obligations under this Agreement.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles.

Entire Agreement

This document, including any attachments and written service orders, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations or agreements, whether written or oral. Any amendment or modification must be in writing signed by both parties.

Acknowledgment and Certification

By signing below the Service Provider certifies that the tests and any repairs documented herein were performed by a qualified technician in accordance with applicable industry standards and local regulations, and that records of test results will be retained in accordance with regulatory requirements.

Client:

By:

Date:

Service Provider:

By:

Date:

What the Backflow Testing Form Is and when it’s used

A Backflow Testing Form documents inspection and test results for a backflow prevention assembly to verify potable water protection. The form records device make, model, serial number, assembly location, test readings, pass/fail status, corrective actions, and tester credentials. Utilities, municipalities, and water suppliers typically require an official form after periodic testing or following repairs. Records created from the form provide a legal and operational record for code compliance, municipal reporting, insurance, and property management.

Why completing a correct Backflow Testing Form matters

A properly completed form protects public health, documents regulatory compliance, and creates a clear chain of responsibility for any corrective work. It reduces inspection delays, supports billing or permit processes, and preserves evidence in case of water contamination or code enforcement.

Typical users and stakeholders for this form

Who needs or completes a Backflow Testing Form depends on property type, local rules, and who maintains the plumbing.

Licensed testers and plumbers — Perform and certify tests according to manufacturer and local code requirements.
Property owners and managers — Maintain records, schedule re-tests, and file results with utilities.
Municipal water departments — Receive reports, enforce compliance, and update cross-connection control logs.

The form also serves as a permanent record retained by property owners and often submitted to the local water authority.

Step-by-step: completing and submitting the Backflow Testing Form

Follow these stages from preparation through submission to ensure an accepted record.

01

Prepare Equipment: Verify calibration and gather manufacturer test kit.
02

Record Device Info: Enter serial, model, and exact installation location.
03

Perform Test: Execute test method, record readings, note corrective actions.
04

Submit Results: Send form to the water authority and retain a copy for records.

Typical workflow from testing to municipal acceptance

A standard workflow moves from on-site testing to form completion, delivery to the authority, and record retention by the property owner.

On-site Test: Technician conducts test and records readings.
Form Completion: Technician fills every required field and signs.
Delivery: Form sent to the water utility or uploaded to their portal.
Retention: Owner retains a copy for compliance and audits.

Configuring an online completion workflow

When digitizing the form, configure fields, signer roles, and submission endpoints to match municipal requirements.

Field	Configuration
Required Fields	Make owner, device, test date, and tester credentials mandatory.
Signer Role	Assign technician as primary signer with certification field.
Authentication	Use email or SMS code for signer verification.
Delivery	Auto-send PDF to utility and owner after signing.

Digital formats and integration points for eSubmission

Ensure your digital process supports the file formats and integrations needed by local water authorities and recordkeeping systems.

File Types: PDF and DOCX supported for official records
Integrations: Connectors for cloud storage and municipal portals
Authentication: Email, SMS, or advanced signer verification

Use platform features that preserve audit trails, generate tamper-evident PDFs, and automate distribution to owners and utilities.

Essential sections every professional Backflow Testing Form should include

A complete form balances device identification, precise test data, tester credentials, and clear disposition instructions so authorities can accept results without follow-up.

Device Identification

Manufacturer, model, serial number, and installation location. Exact device data prevents ambiguity during enforcement or replacement.

Test Readings

Inlet/outlet pressures, differential readings, and pass/fail results reported to standard decimal places and units for technical accuracy.

Pass/Fail Outcome

Explicit final status and any observed defects; an explicit pass/fail conclusion avoids interpretive errors by reviewers.

Corrective Actions

List repairs, parts replaced, or retest instructions with dates and responsible contractor details for accountability.

Certification Block

Tester signature, license number, company, and test date; required for legal acceptance by many water authorities.

Notes & Attachments

Space for photos, invoices, and calibration certificates to support the test record and inspection findings.

Required data elements to capture on the form

Owner Name: Full legal name

Service Address: Street, city, state, ZIP

Device Details: Type, model, serial

Test Date: MM/DD/YYYY

Test Results: Pass/Fail and readings

Tester Info: Name and license number

Consequences of incorrect or missing Backflow Testing Forms

Utility Fines: Administrative penalties

Service Interruption: Possible water shutoff

Liability Exposure: Civil claims for contamination

Reinspection Required: Additional cost and downtime

Insurance Denial: Claims not covered

Regulatory Action: Enforcement or notices

Common mistakes when preparing or submitting the form

Missing or partial device serial numbers leading to ambiguous records and utility follow-ups.
Incorrect test date or time formats that fall outside a required compliance window and trigger rejection.
Incomplete tester credentials (no license number) which invalidate certification and require re-submission.
Failing to attach mandatory supporting documents such as calibration certificates or repair invoices.

Typical timeframes, re-test frequency, and submission expectations

Deadlines vary by utility and device type; confirm local schedules, then follow these common timing rules.

Test Frequency:

Often annually or per local code requirements

Submission Window:

Submit results within 30 days of testing in many jurisdictions

Corrective Retest:

Retest after repairs; timeline varies by authority

Permit Renewal:

Some permits require current test on file

Record Retention:

Retain copies per local retention rules

eSignature vendor comparison for submitting Backflow Testing Forms

Common vendor features and pricing models for eSigning and distributing official test forms. Verify plan details with each vendor before purchase.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about the Backflow Testing Form

Answers to common questions about signing, submission, retention, and what to do if the test fails.

Need help? Contact support

What is a Backflow Testing Form?
A Backflow Testing Form documents test readings, device identification, and tester credentials to confirm the assembly is preventing contaminants entering the potable water supply.
Who may sign the form?
A licensed tester or certified plumber must sign and provide their license or certification number; owners may attest but technician certification is typically required for acceptance.
Can this form be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act and UETA where applicable, provided intent and retention requirements are met and any local notarization rules are observed.
What if the device fails the test?
Document failures and corrective actions on the form, complete repairs, and perform a retest. Submit the failure notice and subsequent passing certification per local authority instructions.
How long should I keep completed forms?
Retain records per local rules; commonly keep them for at least 3–6 years to satisfy audit, insurance, and municipal requirements.
Where do I submit the completed form?
Submit to the local water utility or cross-connection control office via their portal or email address; if unclear, contact the water authority for the accepted submission method.

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