Columbia, IL · Monroe County
Backflow Device Test Inspection Form
Certified testers use this form to report a backflow device inspection, test results, repairs, and information about the property and assembly.
What this form is
This form records a backflow device test, including assembly details, test results, repairs, and whether the assembly passed. It asks for the property address and owner or contact information, device and hazard details, and certified tester and test equipment information. The form directs the tester to return the completed report to the City of Columbia.
Who needs it
A certified tester completing a backflow device inspection uses this form to report the results and certify that the information is accurate.
How to submit it
Return the completed form to the City of Columbia, 208 S. Rapp Ave., Columbia, IL 62236.
About notarization
This form is signed and dated without a notary; the certified tester certifies the report’s accuracy and provides a signature and date.
How to submit this form
- 1
Download the Form
Download the Backflow Device Test Inspection Form PDF.
- 2
Complete the Report
Fill in the property, assembly, inspection, test equipment, and certified tester details.
- 3
Sign and Date
The certified tester should certify the information, then sign and date the report.
- 4
Return the Form
Return the completed form to the City of Columbia, 208 S. Rapp Ave., Columbia, IL 62236.
Frequently asked questions
- What is the Backflow Device Test Inspection Form for?
- It records backflow assembly information, inspection and test results, repairs, and the certified tester’s information and certification.
- Who completes this form?
- A certified tester completes the report, including the property and device details, test results, equipment information, and tester certification.
- Do I need a notary for the Backflow Device Test Inspection Form?
- No. The certified tester signs and dates the form and certifies that the information is true and accurate; no notary is indicated.
- How do I submit the Backflow Device Test Inspection Form?
- Return the completed form to the City of Columbia at 208 S. Rapp Ave., Columbia, IL 62236.
Need something notarized?
This Backflow Device Test Inspection Form doesn’t need a notary — but Illinois residents can notarize other documents online with a commissioned online notary.