Russia, OH · Shelby County
Backflow Preventer Test Report
The Village of Russia uses this report to record backflow preventer test results and device details submitted by the tester or customer.
What this form is
Use this report to document testing of a backflow preventer, including test results, repairs, device type, and customer and device information. The form includes sections for reduced pressure devices, double check valve assemblies, and pressure type vacuum breakers, with options for new device or re-certification and containment or isolation. It does not state when testing is required.
Who needs it
A tester or customer completing a backflow preventer test for a device in the Village of Russia can use this report.
How to submit it
Return the completed form to Village of Russia, PO Box 361, Russia, OH 45363.
About notarization
This report is completed without a notary; the tester provides a signature, certification number, and expiration date, and no sworn attachment is listed.
How to submit this form
- 1
Download The Report
Download the Backflow Preventer Test Report PDF.
- 2
Complete The Test Information
Fill in the applicable test results, repairs, tester certification details, customer information, and device details.
- 3
Check The Completed Report
Review the report fields for the backflow preventer type, test results, signature, and requested information.
- 4
Return The Report
Send the completed form to Village of Russia, PO Box 361, Russia, OH 45363.
Frequently asked questions
- What is the Backflow Preventer Test Report?
- It records backflow preventer test results, repairs, device information, and customer details for the Village of Russia.
- Who completes this report?
- The report requests the tester’s name, signature, certification number, and expiration date, as well as customer and device details.
- Do I need a notary for the Backflow Preventer Test Report?
- No. This report is completed without a notary; the tester provides a signature, certification number, and expiration date, and no sworn attachment is listed.
- How do I submit the Backflow Preventer Test Report?
- Return the completed form to Village of Russia, PO Box 361, Russia, OH 45363.