What does the backflow prevention report record?

It records facility and assembly information, installation details, initial test results, repairs and materials used, and test results after repairs.

Who signs the report?

The tester signs and dates the test certification. The facility owner or officer signs and dates the facility certification.

How do I submit the backflow report?

Return the white copy to the Village of Buckeye Lake Water Department at P.O. Box 2480, Buckeye Lake, OH 43008.

Do I need a notary for the backflow report?

No. The tester and owner or officer sign and date the report; it identifies no notarized attachment or related step.

Buckeye Lake, OH · Licking County

No notary required

Annual Test and Maintenance Report for Backflow Prevention Assemblies

This report records annual testing and maintenance of a backflow prevention assembly for the facility owner and certified tester to submit to the Village.

What this form is

The report documents assembly details, installation information, initial test results, repairs, and test results after repairs. The tester certifies the test information and the facility owner or officer certifies the assembly’s use and condition during the interval between tests. The form identifies the Village Water Department as the recipient of the white copy.

Who needs it

A facility owner or officer and the tester complete the report for a backflow prevention assembly tested at the facility.

How to submit it

Return the white copy to the Village of Buckeye Lake Water Department, P.O. Box 2480, Buckeye Lake, OH 43008. The form lists (740) 928-7100 as the department phone number.

About notarization

This document is signed and dated by the tester and owner or officer without a notary; the form identifies no notarized attachment or related step.

How to submit this form

1
Download The Report
Download the Annual Test and Maintenance Report for Backflow Prevention Assemblies.
2
Complete Assembly Details
Enter facility, assembly, installation, test, repair, and materials information.
3
Sign And Date
The tester and facility owner or officer complete their certifications and sign and date the report.
4
Return The White Copy
Mail the white copy to the Village of Buckeye Lake Water Department, P.O. Box 2480, Buckeye Lake, OH 43008.

Frequently asked questions

What does the backflow prevention report record?: It records facility and assembly information, installation details, initial test results, repairs and materials used, and test results after repairs.
Who signs the report?: The tester signs and dates the test certification. The facility owner or officer signs and dates the facility certification.
How do I submit the backflow report?: Return the white copy to the Village of Buckeye Lake Water Department at P.O. Box 2480, Buckeye Lake, OH 43008.
Do I need a notary for the backflow report?: No. The tester and owner or officer sign and date the report; it identifies no notarized attachment or related step.

Need something notarized?

This Annual Test and Maintenance Report for Backflow Prevention Assemblies doesn’t need a notary — but if you have another Buckeye Lake form that does, a commissioned online notary can help.