Annual Test And Maintenance Report For Backflow Prevention Devices Form
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1WARREN COUNTY COMBINED HEALTH DISTRICT
OFFICE USE ONLY
DIVISION OF PLUMBING
RECERTIFICATION
416 S. East Street, Lebanon, Ohio 45036
Permit:
Phone: (513) 695-1476 – Middletown (513) 261-1476
Fee:
$25.00
Date:
ANNUAL TEST AND MAINTENANCE REPORT FOR
BACKFLOW PREVENTION DEVICES
INVALID IF NOT FILLED OUT COMPLETELY
Reduced Pressure Principle Backflow Preventor
Containment
Double Check Valve Assembly
Isolation
Pressure Vacuum Breaker
Name & Address of Owner
of Device:_________________________________________________________________________________
Address:______________________________________________City:___________State:______ Zip:_______
Address of Device __________________________________________________City:__________State:______
Make and Model:___________________________________________________Size:____________________
Serial No:_____________________________________________________Date Installed:_________________
Exact Location of Device_____________________________________________________________________
Line Pressure
Check Valve #1
Check Valve #2
Differential Pressure
___________psi
Relief Valve
Test Before Repair
Leaked ( )
Leaked ( )
Opened at _________psi
Closed Tight ( )
Closed Tight ( )
Reduced Pressure
Describe Repair
Material Used
Final Test
Closed Tight ( )
Closed Tight ( )
Opened at _________psi
Reduced Pressure
CERTIFICATION (tester)
I hereby certify the above date to be correct and that the above backflow prevention device is in proper operating condition.
Tester: (signature):________________________________________________________________State of Ohio Cert. No:__________
Tester: (print):______________________________________________________Phone #__________________Date:_____________
CERTIFICATION (company)
I hereby certify that the above backflow prevention device has been in constant use at this location during the entire prescribed
interval between test periods and during that period this device was not by-passed, made inoperative or removed without proper
authorization. All defects found during the operation period or during tests of device were satisfactorily corrected without delay.
I further certify that I have the responsibility and authority to insure the above.
Owner/Officer (signature):_________________________________________________________Title:_________________________
Owner/Officer (print):_____________________________________________________________Date:________________________
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