Fillable City Of Fairfield Backflow Test Report Form

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City Of Fairfield Backflow Test Report Form

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ANNUAL TEST & MAINTENANCE REPORT
FOR BACKFLOW PREVENTION ASSEMBLIES
City of Fairfield, Public Utilities Department, Water Division
(513) 858-7775
Assembly Address:________________________________ Business Name: __________________________________
CONTACT INFORMATION
Contact Name/Owner: _____________________________ Phone:__________________________________________
Mailing Address: _________________________________ City, State, & ZIP: ________________________________
E-mail: __________________________________________________________________________________________
BACKFLOW TEST INFORMATION CONTAINMENT*
WATER SUPPLIER: City of Fairfield
*Containment ONLY. Isolation (plumbed after containment) should be sent to the Butler County Health Dept.
TYPE:___________ SIZE:_________ MFR.:____________ MODEL:____________ SERIAL NO.:______________
WATER LINE: DOMESTIC
FIRE LINE FIRE BYPASS IRRIGATION 
EQ
UIPMENT LOCATION IN FACILITY: _____________________________________________________________
NEW INSTALL EXISTING REPLACEMENT PREVIOUS SERIAL NO.:______________
WHEEL CHECK CHECK RELIEF
SUPPLY PSI: ______ VALVES VALVE #1 VALVE #2 VALVE (RP)
T
EST BEFORE REPAIR LEAKED
LEAKED LEAKED OPENED AT ______PSID
D
ATE______________ CLOSED TIGHT
CLOSED TIGHT ______PSID CLOSED TIGHT ______PSID DID NOT OPEN
D
ESCRIBE REPAIR____________________________________________________________________________________________________________________
FINAL TEST CLOSED TIGHT
CLOSED TIGHT ______PSID CLOSED TIGHT ______PSID OPENED AT ______PSID
D
ATE______________
CERTIFICATION (TESTER)
I hereby certify the above data to be correct and that the above BFP device is in the proper operating condition.
T
ester (print): _______________________________________________ State of Ohio Cert. No. __________________
Tester (signature): ___________________________________________ Date: ____________ Phone #: _____________
Company Name: ___________________________________ Address: _______________________________________
CERTIFICATION (BUILDING OWNER OR AGENT)
I hereby certify that the above backflow prevention device has been in constant use at this location during the entire prescribed interval
between test periods and during that period this device was not by-passed, made inoperative, or removed without proper authorization. All
defects found during the operation period or during testing of device were satisfactorily corrected without delay. I further certify that I have
the responsibility and authority to insure the above.
Owner/Agent (print): _________________________________________ Title: ________________________________
Owner/Agent (signature): _______________________________________________ Date: _______________________
Mail to: C
ity of Fairfield Water Division Fax to: (513) 829-3536 E-mail to: public_utilities@fairfield-city.org
5021 Groh Lane
Fairfield, OH 45014
Rev. 10/2017
City of Fairfield, Ohio – Water Division
Quick Reference Guide on Backflow Program Requirements
1. A testable backflow preventer is required on each water line (including fire lines, fire bypass lines,
and irrigation lines) entering an industrial or commercial building. Most often a reduced pressure
principle assembly (RP- ASSE 1013 or RPDA- ASSE 1047) is required. For fire lines and some low risk
situations, a double check valve assembly (DC- ASSE 1015 or DCDA- ASSE 1048) may be allowed.
a. These backflow prevention assemblies are called ‘containment’ assemblies because they
act to ‘contain’ any potential pollution source to inside the facility and thereby protect
the public water system. Fairfield tracks all ‘containment’ assemblies.
• A containment backflow preventer is generally installed immediately
downstream of the water meter when the meter is inside, or at the “point of
entry” when the meter is outside. The backflow preventer should be installed
according to manufacturer specifications and be protected from freezing.
b. ‘Isolation’ backflow prevention assemblies are plumbed after containment assemblies
and act to ‘isolate’ any potential pollution source between areas or processes within the
same building; these types of assemblies are often found in large industrial facilities as
well as in buildings occupied by multiple tenants. The Butler County Health Department
tracks all ‘isolation’ assemblies.
2. Upon installation or repair, each backflow preventer must be tested by an Ohio certified tester to
confirm it is functioning properly. Test reports must be submitted to Fairfield’s Water Division.
3. At least once every twelve (12) months, each backflow preventer must be tested by an Ohio
certified tester, and repaired if needed, to confirm it is functioning properly. Test reports must be
submitted to Fairfield’s Water Division.
4. For more information on Fairfield’s backflow program, including access to blank test report forms
and links to the State and Local regulations governing backflow, please visit:
http://www.fairfield-city.org/283/Backflow-Prevention
5. For questions about Fairfield’s backflow program, please call the City’s Water Treatment Plant at
513-858-7775. Test reports may be emailed to public_utilities@fairfield-city.org
The City of Fairfield is required by Ohio State Law to administer a backflow prevention
program as a means to protect the public water supply from potential contamination.
Fairfield's program is designed to prevent the flow of water from a consumer's private piping
back into the public water distribution system. Backflow prevention is primarily accomplished
through the installation of backflow prevention assemblies on a consumer's water pipes.
It is the responsibility of the water consumer to install, maintain, and have tested all
backflow prevention assemblies associated with the consumer’s facility.
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Completed 14 July 2020

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