Celina, OH · Mercer County
Backflow Preventer Test Report
This report records backflow preventer test results and is completed by a tester for a device at a customer’s property.
What this form is
The report documents a backflow preventer test, including the device type and identification details, test results, and any repairs made. It asks for customer and device information, tester details, the tester’s certification number and expiration date, and a date and signature; the form does not state when testing is required.
Who needs it
A tester completing a backflow preventer test for a customer can use this report to record the device and test information.
How to submit it
Return the completed form to the Celina Water Department, 714 S. Sugar Street, Celina, Ohio 45822.
About notarization
This document is signed without a notary; the tester signs and dates the report, and no notarized or sworn attachment is mentioned.
How to submit this form
- 1
Download The Report
Download the Backflow Preventer Test Report PDF.
- 2
Complete The Form
Fill in the customer, device, test, repair, and tester information requested on the report.
- 3
Sign And Date
The tester prints and signs their name and enters the date and certification details.
- 4
Return The Report
Return it to the Celina Water Department at 714 S. Sugar Street, Celina, Ohio 45822.
Frequently asked questions
- What is the Backflow Preventer Test Report for?
- It records customer and device information, backflow preventer test results, any repairs, and the tester’s certification details.
- Who completes the report?
- The form has fields for customer and device details as well as the tester’s printed name, signature, certification number, and expiration date.
- Do I need a notary for the Backflow Preventer Test Report?
- No. The tester signs and dates the report; the document does not mention a notarized or sworn attachment.
- How do I submit the Backflow Preventer Test Report?
- Return the completed form to the Celina Water Department, 714 S. Sugar Street, Celina, Ohio 45822.
Need something notarized?
This Backflow Preventer Test Report doesn’t need a notary — but if you have another Celina form that does, a commissioned online notary can help.