Building & Zoning Department
215 S. Broadway, Louisburg, KS 66053
913-837-5371 · louisburgkansas.gov
Backflow Certificate
Inspections are required in accordance with ordinance #959 and the Code of the City of Louisburg. Testing intervals shall
not exceed one (1) year and backflow preventers shall be overhauled as required to keep the device in proper working
order. Backflow preventers are required on commercial buildings and lawn irrigation (sprinklers) where backflow may
occur and where there is a hazard of contamination of potable water supply.
Customer Name: ____________________________________________________________________________________
Service Address: _____________________________________________________________________________________
Customer Phone: ____________________________________________________________________________________
Name of Tester: _____________________________________________________________________________________
Certification Number: ________________________________________________________________________________
Expiration Date: _____________________________________________________________________________________
Company Name: ____________________________________________________________________________________
Company Phone: ____________________________________________________________________________________
Hazard: ____________________________________________________________________________________________
Location of Assembly: ________________________________________________________________________________
Manufacturer: Serial Number: _________________________________________________________________________
Model Number: ________________________________________ Size: ________________________________________
Date of Test: _____________________ Check #1 (psid) ____________________ Check #2 (psid) ____________________
Repairs Made: ______________________________________________________________________________________
Comments: _________________________________________________________________________________________
__________________________________________________________________________________________________
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