Backflow Prevention Certification Form Submission

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Use this form to submit a completed Backflow Prevention Assembly Test Report to the Camino Real Regional Utility Authority.

Please complete the official fillable PDF and upload the finalized document at the time of submission.

Important: All required fields must be completed before submitting. Incomplete submissions may delay processing.

Customer Information

Owner's Name

Premise Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Business Name

Point of Contact

Phone

Current Assembly Information

Manufacturer:

Model:

Serial No.

Size:

Tag:

Type of Service:

Containment/Domestic

Containment/Lawn Irr.

Containment/Fire Sys

Isolation

Specific physical location of assembly:

If isolation, indicate type of equipment or system isolated:

Test Result

Pass

Fail

Removed Assembly Information

Manufacturer:

Model:

Size:

Serial No.

Gauge Information

ID:

Manufacturer:

Model:

Serial No.

Date of Last Calibration:

RP

CV1 AR

CV2 Tight?

Yes

CV1 CR

CV2

DC

CV1

CV2

(PVB) AIV

(PVB) CV

(SVB) AIV

(SVB) CV

Test Type:

Initial

Annual

Repair

Additional Requirements

Thermal Expansion Control Present?

Yes

(Containment domestic only)

Unknown

Requirements made known?

Yes

Adequate Freeze Protection Present?

Yes

N/A

Requirements made known?

Yes

N/A

Comments or Repairs Made:

The backflow prevention assembly detailed on this report has been tested and maintained as required and is certified to be operating within acceptable parameters. I also certify that I tested this assembly and the test results are true.

Tester ID:

Name:

Firm:

Firm Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date & Time

Date & Time: Date

Date & Time: Time

CRRUA Address

Sunland Park Multi-Generational Center
4700 McNutt Rd.
Sunland Park, NM 88008

Business Hours:

Lobby: 8 a.m. to 4 p.m.
Phone: 8 a.m. to 5 p.m.
Monday – Friday

*Closed on Weekends and National Holidays