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2. Backflow Prevention Test Form

   This document must be completed and returned by a certified tester to the Springboro Water Department.

   
   

4. Please mark the appropriate box:

   1. New Device

   1. Annual Test
6. Facility Name:*
8. Property Owner Address:*
10. Contact Person:*
11. Phone #:*
13. Please Check:

    1. Fire Line

    1. Irrigation

    1. Main Live

    1. Isolation
15. Backflow Prevention Device Information
17. Size:*
18. Make:*
19. Model:*
20. Serial #:*
22. Location of Device:*
23. Date of Test:*
    Date of Test:
25. Reduced Pressure Backflow Prevention Device (ASSE 1013)
27. Outlet Valve*

    1. Pass
    2. Fail
28. Check Valve #1
29. Check Valve #2
30. Differential Pressure Relief Valve
32. Test Before Repair
33. Valve #1

    1. Leaked
    2. Closed Tight
34. Valve #2

    1. Leaked
    2. Closed Tight
35. Opened at

    Reduced Pressure

37. Describe Repairs
38. Valve #1
39. Valve #2
40. Opened at

    Reduced Pressure

42. Final Test
43. Valve #1

    1. Closed Tight
44. Valve #2

    1. Closed Tight
45. Outlet Valve*

    1. Pass
    2. Fail
47. Test Performed By:*

    (Name)

49. Certified Tester #:*
50. Expiration Date:*
52. Plumbing Company:*
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field