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Backflow Prevention Test Form

  1. Backflow Prevention Test Form

    This document must be completed and returned by a certified tester to the Springboro Water Department.


  2. Please mark the appropriate box:
  3. Please Check:
  4. Backflow Prevention Device Information
  5. Reduced Pressure Backflow Prevention Device (ASSE 1013)
  6. Outlet Valve*
  7. Differential Pressure Relief Valve
  8. Test Before Repair
  9. Valve #1
  10. Valve #2
  11. Reduced Pressure

  12. Describe Repairs
  13. Reduced Pressure

  14. Final Test
  15. Valve #1
  16. Valve #2
  17. Outlet Valve*
  18. (Name)

  19. Leave This Blank:

  20. This field is not part of the form submission.