The Backflow Certification form is the City of Cape Coral Utilities report on which a backflow prevention device is field tested and its maintenance recorded, under the Cross Connection Control Program. It covers new installations, existing units and replacement units, and for new and replaced devices it asks for a service permit number, so it relates to a Cape Coral permit. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the city publishes the original PDF at the official link.
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What is Backflow Certification form – Cape Coral, FL?
The Backflow Certification form is the City of Cape Coral Utilities form headed "Cross Connection Control Program – Backflow Prevention Device Field Test & Maintenance," used to record the test results and any repairs for one backflow prevention device.
At the top you check whether the device is a New Installation, an Existing Unit or a Replacement Unit. The form then identifies the customer address and unit number, the device (manufacturer, size, assembly type, model number, serial number, date installed and installer) and the service it protects: fireline, potable or irrigation. A permit number is required for new and replaced devices, and the form also has a meter number line.
The main grid records an initial test, any parts and repair, and a final test. Each device type on the form has its own columns: reduced pressure, pressure vacuum breaker, double check and detector loop device. Entries note whether each check valve passed or leaked (PSID), and whether the relief valve or air inlet opened and at what PSID or did not open.
The tester signs a certification that the data is accurate and reflects the actual operation and maintenance of the assembly, and the form ends with a Passed or Failed box. The form states that all repairs shall be completed within 10 business days and that only one test form is used per device.
Who needs to file Backflow Certification form – Cape Coral, FL?
The form is completed for each backflow prevention device that is tested under the City of Cape Coral Cross Connection Control Program, whether the device is a new installation, an existing unit or a replacement unit.
In practice the people who fill it out are:
- The tester, who enters the test results, the test date and time, the tester certification number and company, and signs the certification that the data is accurate.
- The customer (the owner or occupant served by the device), whose address is entered and who signs on the customer signature line.
For a new or replaced device, the form requires a permit number for the service (fireline, potable or irrigation) that the device protects.
Do not combine several devices on one sheet: the form says one test form per device only. If a device has more than one service line, such as separate fireline and irrigation assemblies, each assembly needs its own form. The form does not describe who may sign for a customer, so ask the city if someone other than the customer will sign.
When to file Backflow Certification form – Cape Coral, FL
The form is completed when a backflow prevention device is field tested, whether it is a new installation, an existing unit or a replacement unit. The test date and time are entered on the form itself.
If the initial test shows a problem, the form has rows for parts and repair and for a final test. The form states that all repairs shall be completed within 10 business days, so the final test is recorded after that work is done.
No separate due date for submitting the form is printed on it. For deadlines tied to a permit or to the test schedule for your device, contact the City of Cape Coral Land Development Division at (239) 573-3167 or [email protected].
How to fill out Backflow Certification form – Cape Coral, FL
Check the device status
At the top, under Please Check One, mark New Installation, Existing Unit or Replacement Unit.
Enter customer address and unit
Fill in the Customer Address and the Unit # where the device is installed.
Describe the device
Enter the manufacturer, size, assembly type, model # and serial #, then the date installed and who installed it.
Choose the service type
Check one of Fireline, Potable or Irrigation, and enter the service permit #. The permit number is required for new and replaced devices; enter the meter # on its line.
Record the initial test
In the column group for your device type (reduced pressure, pressure vacuum breaker, double check or detector loop device), mark whether each check valve passed or leaked and record any PSID readings. For the relief valve or air inlet, note the PSID it opened at or that it didn't open.
Record parts, repairs and final test
Use the parts and repair row for work performed, and the final test row for the results after repair. All repairs must be completed within 10 business days.
Add comments
Print any needed notes in the Comments area.
Complete tester information
Enter the tester certification #, company, test date and test time, then have the tester sign the certification that the data is accurate.
Mark the result and customer signature
Check Passed or Failed, and have the customer sign on the customer signature line.
Review and download the PDF
Check that you used one form for this device only and that every needed field is filled, then download or print the completed PDF from FillingPDF and deliver it as described under How to submit.
How to submit Backflow Certification form – Cape Coral, FL
The form prints no mailing address, portal, email or office for returning it, so confirm the channel with the city before you deliver it.
- City contact: the City of Cape Coral Land Development Division page on other development permits gives (239) 573-3167 and [email protected] for assistance with the permits and forms it lists. Ask there where the completed test form goes and whether it is filed with a permit.
- Original PDF: the city publishes the form at the official link on this page.
Before you send it, check that the tester and customer have both signed, that the test date and time are entered and that one of the Passed or Failed boxes is checked. Include the permit number for a new or replaced device. FillingPDF lets you fill out and download the PDF; submission follows the city's channels, not this site.
Common mistakes to avoid
- Leaving all three boxes (New Installation, Existing Unit, Replacement Unit) unchecked; the form says to check one.
- Omitting the service permit number for a new or replaced device, which the form marks as required for new and replaced units.
- Not checking one of Fireline, Potable or Irrigation for the service the device protects.
- Putting the results for more than one device on a single sheet; the form allows one test form per device only.
- Skipping the Passed or Failed box after the final test, so the form shows no result.
- Leaving off the tester certification number, company, test date or test time next to the signature lines.
- Leaving the customer signature or tester signature blank even though the tester certifies the data is accurate.
- Letting repairs run past the 10 business days the form allows after a failed test.
Frequently asked questions
What is the Cape Coral Backflow Certification form?
It is the City of Cape Coral Utilities form for the Cross Connection Control Program, titled Backflow Prevention Device Field Test & Maintenance. It records the identity of one backflow device, its initial and final test results, any repairs and a passed or failed result.
Do I need a separate form for each backflow device?
Yes. The form states one test form per device only. Fill out a separate form for each assembly, even if several devices are at the same address or serve different services such as fireline, potable or irrigation.
Is a permit number required on the backflow test form?
The form marks the permit number as required for new and replaced devices, with a service permit line for fireline, potable and irrigation services. The form does not state a permit requirement for existing units; ask the city if unsure.
How long do I have to complete repairs after a failed test?
The form states that all repairs shall be completed within 10 business days. It has a parts and repair row and a final test row so the work and the repeat test results can be recorded on the same form.
Who signs the Cape Coral backflow certification form?
The form has a tester signature, which certifies that the data is accurate and reflects the actual operation and maintenance of the assembly, and a customer signature. The tester also enters a certification number and company name.
Can I fill out the backflow certification form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not the city, and does not file or transmit the form; you deliver it using the city's channels.
Where do I send the completed backflow test form?
The form prints no delivery address or portal. The Land Development Division page lists (239) 573-3167 and [email protected] for assistance with the permits and forms it lists, so contact them to confirm where the form goes.
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