Backflow Test and Maintenance Form (pdf) - Clermont County, Ohio ... - clermonthealthdistrict 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Facility Name and Address at the top of the form. This information is crucial for identifying where the backflow prevention assembly is located.
3. Fill in the Assembly Information section, including Model, Make, Size, Type, Water Provider, and Serial Number. Accurate details ensure proper documentation.
4. In the Tester Certification area, print your name and provide your signature. Include your phone number and company name along with your Ohio Certification Number and date.
5. Complete the testing results for each valve listed under Initial Test. Indicate whether each component passed or failed by checking the appropriate box.
6. If repairs are needed, document them in the Repairs & Materials Used section and schedule a re-test after repairs are completed.

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