Vermilion, OH · Lorain County
Backflow Annual Test and Maintenance Report
This report records annual backflow prevention assembly test and maintenance results for testers and facility representatives to submit to the city.
What this form is
Testers use this report to record assembly details, test results, repairs, materials, and their certification; a facility representative also certifies the device’s use and condition. The form is for reporting annual tests of backflow prevention assemblies. It requires applicable fields to be completed in ink, and states that incomplete reports will not be accepted.
Who needs it
Testers completing a backflow prevention assembly test and the facility owner or representative who certifies the device’s use should complete this report.
How to submit it
Return the original to Vermilion Backflow, 5511 Liberty Ave., Vermilion, OH 44089, or email [email protected]. All applicable fields must be complete.
About notarization
This report is signed and dated without a notary; the tester and facility representative provide certifications, and no sworn or notarized attachment is listed.
How to submit this form
- 1
Download The Report
Download the Backflow Annual Test and Maintenance Report PDF.
- 2
Complete The Report
Fill out all applicable fields in ink, including assembly information, test results, and required certifications.
- 3
Gather Test Information
Include the test results, any repairs and materials used, and the tester and facility representative certifications.
- 4
Submit The Original
Return the original to Vermilion Backflow at the address on the form, or email it to the listed city contact.
Frequently asked questions
- What does the Backflow Annual Test and Maintenance Report record?
- It records backflow prevention assembly information, test results, repairs and materials used, along with certifications from the tester and facility representative.
- Who completes this backflow test report?
- The tester records the assembly and test information and signs the tester certification. The facility owner or representative completes the facility certification.
- Do I need a notary for the Backflow Annual Test and Maintenance Report?
- No. The report is signed and dated without a notary; the tester and facility representative provide certifications, and no sworn or notarized attachment is listed.
- How do I submit the Backflow Annual Test and Maintenance Report?
- Return the original to Vermilion Backflow at 5511 Liberty Ave., Vermilion, OH 44089, or email it to [email protected]. Complete all applicable fields.