BACKFLOW ASSEMBLY TEST FORM. RETURN … pressure at time of test: ... TESTING COMPANY PHONE NUMBER ... PLUMBING INSPECTION DEPARTMENT FAXPHONE PERMIT # ORIGINAL TEST

Approved BFP

Initial Test By Certificate Gauge Num Company Phone

Final Test By

Repair By

Service Address

Contact Name

Install Date

Mfr

SN

Size

Type

Model

Test Report Due:

Schedule Code

Location ID

Map Page

Permit Num

Hazard Type Haz. Level

Assembly ID

Meter #

Facility Name

Acct Number

Equip Location

Protection Type

#2

Ph

(Replacement/Correction)Assembly Info

R

E

P

A

I

R

Final

Test

Initial

Test

Shut Off ValvesPVB/SVBCheck Valve #1 Check Valve #2 Relief Valve

#2#1

Leaked

Leaked

PSIDLeaked Leaked Did Not Open

CLEANED

REPLACED

CLEANED

REPLACED

CLEANED

REPLACED

CLEANED

REPLACED

CLEANED

REPLACED

1A

Air Inlet Opened at

Air Inlet Disc

Airl Inlet Spring

Check Disc

Check Spring

PSID

REPORT OF TEST RESULTS

Held at

PSID

Disc

Spring

Guide

Seat

Closed Tight

PSID

Disc

Spring

Guide

Seat

Closed Tight

Disc

Spring

Diaphragm

Seat

Opened at

PSID

Closed Tight

PSID

Line pressure at time of test:

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

Date:

Other/Notes:

Held at

PSID

Opened at

PSID PSID

PSID

Air Inlet

CK Valve

Closed TightDid not Open

Check Held atClosed Tight Closed Tight

Other

REPAIR

FloatHinge Pin Hinge Pin O-Ring(s)

DiaphragmDiaphragm Module Module

Module

City of Snoqualamish, WA

BACKFLOW ASSEMBLY TEST FORM.

RETURN ORIGINAL FORM ONLY .

Time In Time Out

Fail

Pass

Pass

Shut Off ValvesCheck Valve #1 Check Valve #2 Relief Valve

#2#1

Leaked

Leaked

PSIDLeaked Leaked Did Not Open

Air Inlet Opened at

PSID

Held at

PSID PSID

Held at

PSID

Opened at

Initial

Test Closed TightDid not Open

Check Held atClosed Tight Closed Tight

Initial Test By Certificate Gauge Num Company Phone

Final Test By

Repair By

CLEANEDCLEANED CLEANED CLEANED CLEANED

Final

Test

REPORT OF TEST RESULTS

Closed Tight

PSID

Closed Tight

Opened at

PSID Closed Tight

Line pressure at time of test:

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

Date:

Comments

PSID PSID

PSID

Air Inlet

CK Valve

City of Snoqualamish, WA

BACKFLOW ASSEMBLY TEST FORM.

RETURN ORIGINAL FORM ONLY .

Time In Time Out

0

Service Address

Contact Name

Location

Install Date

Assembly Info

Mfg

SN

Size

Type

Emergency Ph:

Model

Return Form By:

Schedule Code

Location ID

Map Page

Permit Num

Hazard Type Haz. Level

Assembly ID

Meter #

Facility Name

Acct Number

1B

PVB/SVB

FailedPassed

Passed Final Test

Initial Test

TEST

FINAL

TEST

INI-

TIAL

YR

YR

YR

IF DEVICE REPLACED, WHY?

MAP:

GRID

COMMENTS:

PAGE

SITE CONTACT

WORK PERFORMED

TESTING COMPANY PHONE NUMBER

TESTER #

SITE CONTACT PHONE NUMBER

DAY

TESTING COMPANY

MO

WORK PERFORMED

DAYMO

WORK PERFORMED

DAYMOTESTER #

CHECK VALVE

#2

DIFFERENTIAL

PRESSURE RELIEF

VALVE

AIR INLET

VALVE

CHECK VALVE

#1

CLOSE AT_____ PSID

LEAKED

CLOSE AT_____ PSID OPEN AT_____ PSID OPEN AT_____ PSID

LEAKED

CLOSED TIGHT

OPEN UNDER #2

OR DID NOT OPEN

OPEN UNDER #1

OR DID NOT OPEN

CLEANED CLEANED CLEANEDCLEANED

REPLACED: REPLACED: REPLACED: REPLACED:

BACKFLOW PREVENTION DEVICE

FIELD TESTING AND MAINTENANCE REPORT RETURN NO LATER THAN:

MANUFACTURER

LOCATION

MODEL SIZE SERIAL NUMBER

R

E

P

AI

R

S

SPRING

O-RINGS

MODULE

OTHER

DESCRIBE:

DISC

DISC HOLDER

GUIDE

HINGE PIN

SEAT

SPRING

O-RINGS

OTHER

DESCRIBE:

DISC

DISC HOLDER

CANOPY

DIAPHRAGM

(PRINT NAME)

MAIL TO:

ADDRESS CORRECTION:

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

INITIAL TEST BY (SIGNATURE)

SPRING

O-RINGS

MODULE

OTHER

DESCRIBE:

DISC

GUIDE

SEAT

SPRING

O-RINGS

MODULE

OTHER

DESCRIBE:

DISC(S)

DIAPHRAGM(S)

SEATHINGE PIN

DISC HOLDER DISC HOLDER

OTHER

REPLACEMENTS:

TESTCOCK #1

TESTCOCK #2

TESTCOCK #3

TESTCOCK #4

SHUTOFF #1

SHUTOFF #2

CLOSE AT_____ PSID CLOSE AT_____ PSID OPEN AT_____ PSID OPEN AT_____ PSID

REPAIRED BY (SIGNATURE)

FINAL TEST BY (SIGNATURE)

(PRINT NAME)

(PRINT NAME)

TYPE

XC2-1C

Return Original Test Notices Only.

Copies or Faxes not permitted.

O-RING(S)OTHEROTHER

Initial Test by (Signature) Tester Number MO DAY YR

DISC(S) DISCDISC DISC(S)

FLOATSEATSEAT DIAPHRAGM(S)

MODULE OTHERMODULE SEAT(S)

SPRING SPRINGSPRING SPRING

CLOSED TIGHT CLOSED TIGHT

SEATED________PSIDSEATED________PSID

CLEANED

CHECK VALVE

#2

DIFFERENTIAL PRESSURE

RELIEF VALVE

AIR INLET

VALVE

CHECK VALVE

#1

LEAKED

OPEN UNDER #2

OR DID NOT OPEN

OPEN UNDER #1

OR DID NOT OPEN

INITIAL

TEST

CLEANED CLEANEDCLEANED

REPLACED REPLACED REPLACED REPLACED

R

E

P

A

I

R

S DESCRIBE:DESCRIBE:

DESCRIBE:

FINAL

TEST

DESCRIBE:

SEATED________PSID

OPENED AT________PSID OPENED AT________PSID

LEAKED

SEATED________PSID

CLOSED TIGHT

SEATED________PSID

CLOSED TIGHT OPENED AT________PSID OPENED AT________PSID

THE ABOVE REPORT IS CERTIFIED TO BE TRUE.

RETURNORIGINALFORM TO:

RETURN NO LATER THAN:

MAIL TO:

Name (Please print)

Repaired by Tester Number MO DAY YR

Final Test by (Signature) Tester Number MO DAY YR

BACKFLOW PREVENTION DEVICEFIELD TEST - MAINTENANCE REPORT

City of Snoqualamish, WA

Tap Number Business Name Facility Address

Map Page Room Type Water Use Hazard Location

Protection Type Manufacturer Model Size Serial Number

OTHER

1D

CHECK VALVE #1

CHICAGO WATER DEPARTMENT

BACKFLOW PREVENTER TEST REPORT

PLUMBING INSPECTION DEPARTMENT FAXPHONE

PERMIT # ORIGINAL TEST

DISTRICTAM. PM. DATE RETESTTIME PASS FAIL

CALIBRATION DATETEST KIT

ADDRESS OWNER

CONTACT PHONE FAX

DEVICE = SUPPLY PRESSUREDCDADCRP PVB PSIG

CONTRACTOR PHONE

MFR SIZE MODEL# SERIAL#

ON LINE TO

LEAKED

DID NOT OPEN

OPENED @

OPENED @

COMMENTS

COMPLETETYPE TYPE

PSID / RP ZONE

PSID

RELIEF VALVE

TEST COCKS

MISSING #RWRW

DAMAGEDCLOSED TIGHTCLOSED TIGHT

COMMENTSLEAKEDLEAKED

PSIDPSID

INITIAL TEST CLOSED TIGHT CLOSED TIGHT

LEAKED

COMMENTSCOMMENTS

CLOSED TIGHT

CHECK VALVE #2

CONTROL VALVE #2

COMMENTSCOMMENTS

FINAL TEST

COMMENTS

CCCDI# XC PLUMBING LICENSE#

CCCDI NAME (PRINT) SIGNATURE

CLOSED TIGHT

CONTROL VALVE #1

EXACT LOCATION

1E

Owner of Property

Mailing Address

Device Address

Contact Person

Exact Device Location

Date

Examined by

Certificate #

RPZ DCVA PVB

(Town) (Zip)(ST)

Bronze Iron St. Steel

(Town) (ST) (Zip)

Size

Model No.Make

Serial No.

Reduced Pressure Backflow Preventer

Double Check Valve Assembly

Check Valve No. 1 Check Valve No. 2 Relief Valve

Pressure Vacuum Breaker

Check Valve Air Inlet

Initial Test

Closed Tight

Leaked

________PSID

Opened at

Did Not Open

Repairs

Test After Repairs

Condition of No. 2 Shutoff Valve

________PSID

Opened atClosed Tight

Leaked

________PSID Did Not Open

________PSID

Closed Tight Closed Tight Closed TightOpened at Opened at

________PSID________PSID ________PSID ________PSID________PSID

Closed Tight

Closed Tight Leaked

Leaked ________PSID

Inspection and Maintenance Backflow Prevention Device

Report Form

1F

Owner Agent

Witnessed by: PASS FAIL

Water Works Official

State Official

Certified Tester

Remarks

Tester Certfication: I certify that the foregoing test report is correct.

Permit Number

Repairs

Exact Device Location

Reduced Pressure Backflow Preventer

Double Check Valve Assembly

Check Valve No. 1 Check Valve No. 2 Relief Valve

Pressure Vacuum Breaker

Check Valve Air Inlet

Initial Test/Routine Test

Closed Tight

Leaked

________PSID

Opened at

Did Not Open

Test AfterRepairs

Condition of No. 2 Shutoff Valve

________PSID

Opened atClosed Tight

Leaked

________PSID Did Not Open

________PSID

Closed Tight Closed Tight Closed TightOpened at Opened at

________PSID________PSID ________PSID ________PSID________PSID

Closed Tight

Closed Tight Leaked

Leaked ________PSID

Backflow Prevention Device

Inspection and Maintenance

Report Form

1FB

MA License Plumbers/FSF Name (Print)

Repair Person: These devices must be repaired by a Massachusetts Licensed Plumber or a Fire Sprinkler Fitter.

PASS FAIL

The Above Test/Inspection is Certified to be True

TEST RESULT

Plumber/FSF Lic # Cert. Exp Date Signature

Initial

Re-Test

Annual

Semi-Annual

Test Status

Public Water System Name PWS City/Town PWS ID Number

City of Snoqualamish, WA Snoqualamish

Date

MA-DEP Certified Tester Name (Print) MA-DEP Cert Tester ID Cert. Exp Date Signature Date

Backflow Device Test Conducted by: (MA - DEP Backflow Prevention Device Tester)

Backflow Device Test Witnessed By: (Facility Owner/Representative)

Facility Owner/Representative (Print) Signature Date

Date

Date

Date

Owner of Property

Mailing Address

Device Address

Contact Person

RPZ DCVA PVB

(Town) (Zip)(ST)

Bronze Iron St. Steel

(Town) (ST) (Zip)

Size

Model No.Make

Serial No.

Permit Number

Valve Type: OS&Y Butterfly Other

Domestic Line Fire Sprinkler Line

Ball

Line Pressure: __________

Tester's Certification

Water Use Protection Test Report

Notes & Repairs

PRINT NAME

SIGNATURE

DATE OF TEST

TESTER # TEST KIT #

1G

Tests COMPONENTSTEP TEST REQUIREMENT INITIAL TEST FINAL TEST

REDUCED

PRESSURE

DOUBLE CHECK

VALVE

PRESSURE

VACUUM BREAKER

Relief Valve Opening Pressure2: PSID min

Check Valve 2 Held against Backpressure (yes/no)3: yes

Buffer5: Confirmed Pressure - Relief Valve Pressure PSID pref.

Air Inlet Valve1: Opening Differential PSID min

Check Valve2: Closes tight in direction of flow PSID min

Apparent Pressure DropCheck Valve 11:

4: Check Valve1 Confirmed Pressure Drop PSID min

1: Check Valve 1 Differential Pressure in direction of flow PSID min

2: Check Valve 2 Differential Pressure in direction of flow PSID min

5.0

2.0

1.0

1.0

1.0

1.0

3.0

Protection

USETYPE

SIZEMODELMANUFACTURER SERIAL NUMBER

DEVICE ID

Facility

Water Use

BUSINESS NAME FACILITY ID

WATER ACCT CONTACT TITLE

PHONE

FAX

EXT

CODEMETER NO.

TAP NUMBER MAP PAGE FLOOR ROOM ROOM TYPE METER NUMBER

Water Use

Notes:Back Pressure:

Continuous Pressure:

Address:

Hazard:

Location:

Description:

Type:

0

Test Gauge Used: Manufacturer/Model: SN: Calibration Date:

Tester Name:

Company Address:

Test Acknowledged By:

Company Name:

Phone #:

Certified Tester #:

The above is certified to be true at the time of testing:

Service Restored:

Remarks

The backflow prevention assembly detailed above has been tested and maintained as required by TCEQ regulations and is certified to be operating within

acceptable parameters.

Pressure Vacuum Breaker

Final Test

Initial Test

Repairs andMaterials Used

Test Date Reduced Pressure Principal Assembly

Double Check Valve Assembly Check Valve

Check Valve #1 Check Valve #2

Air Inlet

Relief Valve

Leaked

PSID

PSID

Leaked Leaked Did Not Open

Contact Name

Mfg:

Serial Number

Size: Model:

Map Page

PSID

Held at PSID

PSID

Held at PSIDOpened at

Did not Open

Closed Tight Closed Tight

PVB SVB DC DCDA RP RPDA Air Gap Other

Held at PSID

PSID

Held at PSID Opened at

Closed Tight Closed Tight

Existing New Replacement

Replaces SN#

PSID

Opened at Held at

Opened at Held at

Is the Assembly installed in accordance with manufacturers recommendations and/or local codes? Yes No

Water Turn Off Authorization: (Print) Time:

Yes No

Service Address

Location IDFacility Name

Phone:

Mailing Name

City/ST/Zip Telephone

Address 1

ST: Zip:

Assembly Information

Assembly Location Information

Zip:

Hazard Type

Equip Location

Property Information

Fail

Pass

Fail

Pass

PWS ID:(206) 555-1213

PSID PSIDPSID

. . .

Check Valve #1 Check Valve #2 Relief Valve

RPP

DCV

Opened atClosed Tight Closed Tight

Leaked Leaked Did Not Open

Opened Under 2.0 PSID

(Replacement/Correction)

City of Snoqualamish, WA

Fail

Service Address

Device Install Date

Mfr

SN

Size

Type

Model

Schedule Code

Location ID

Permit Num

Acct Number

Assembly Info

BACKFLOW ASSEMBLY TEST FORM.

RETURN ORIGINAL FORM ONLY .

Pass Outside Tester See Comments

INSPECTION RESULTSASSEMBLY UNTESTABLE

Unapproved Assembly

Shut-Off Valves

No Access

#1 #2

Test Cocks

Damaged

Shut-Down not Possible

#1 #2 #3 #4

ASSEMBLY INSTALLED INCORRECTLY

Distance from Meter

Clearance

Height

Configuration

ASSEMBLY FAILURE

Shut-Off Valves Not Holding

Check Valves Not Holding

Pressure Relief Valve

#1 #2

#1 #2

Inadequate Buffer

Fouled Not Opening Opening Under

NO BACKFLOW PROTECTION / MISSING UNPROTECTED CROSS-CONNECTION

COMMENTS

REQUIRED CORRECTION

Install Approved RPP Device per Diagram

Have above Referenced Assembly Repaired

Have Assembly Tested

Install Assembly Directly Behind Meter

Call: Regarding:

Install Approved DCV Device per Diagram

Replace with Approved Shut-Off Valves

Remove/Protect Cross-Connection By-Pass

Expose Piping for Inspection

2.0 PSID

By Certif # Date

Compliance is requested in accordance with Title 17 of the California Administrative Code and the SJWC Cross Connection Control Program.

Device Inspected By

Last Tested Date

Last Tested By

Facility Name

Meter #1 / #2

Meter Location

Phone #1 / #2

Contact Name

Mailing Address

Mailing City/State

Comments: Notes:

Final

TestApparent Air Inlet

CK Valve

PSID

PSID Closed TightClosed Tight

PSID Opened at

PSIDActual

Initial

Test

Leaked

Check Held at

PSID Leaked

Closed Tight

Leaked

Closed Tight

Leaked

Did Not OpenActual

Did not Open

PSIDPSIDPSIDApparent

PVB/SVB Shut Off ValvesRelief ValveCheck Valve #2Check Valve #1

Air Inlet Opened at #2#1 Held atHeld at PSID Opened at

R

E

P

A

I

R

CLEANED

REPLACED

Air Inlet Disc

Airl Inlet Spring

Check Disc

Check Spring

Float

Diaphragm

CLEANED

REPLACED

Other

REPAIR

CLEANED

REPLACED

Disc

Spring

Guide

Seat

Hinge Pin

Module

CLEANED

REPLACED

Disc

Spring

Guide

Seat

Other/Notes:

Hinge Pin

Diaphragm

Module

CLEANED

REPLACED

Disc

Spring

Diaphragm

Seat

O-Ring(s)

Module

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

Initial Test By

Final Test By

Repair By

Line pressure at time of test:

Protection Type

1. Is the device installed per:

2. Is there a strainer or Pressure Regulator

between Meter and Backflow Preventer?

REQUIREMENTS

CompanyTime Out PhoneGauge Num Time InDate:Certificate

Yes No

3. Is there PVC Pipe

between Meter and Backflow Preventer?

4. Is there a Tee

between Meter and Backflow Preventer?

Yes No

City of Snoqualamish, WA

0

Service Address

Contact Name

Install Date

Mfr

SN

Size

Type

Model

Return Form By:

Schedule Code

Location ID

Map Page

Permit Num

Hazard Type Haz. Level

Assembly ID

Meter #

Facility Name

Acct Number

Equip Location

#2

Ph

(Replacement/Correction)Assembly Info

1H

BACKFLOW ASSEMBLY TEST FORM.

RETURN ORIGINAL FORM ONLY .

Held at PSID

Check Valve #1 Check Valve #2Differential

Pressure Relief Valve

Air Inlet Opened at

PSID

R

E

P

A

I

R

S

Initial

TestPSID

REPLACED REPLACED REPLACED

PSID PSID

Opened at Check Held at

PSID

REPLACED

Double Check Valve Assembly OR Reduced Pressure Principle Assembly

Back Pressure

Pressure Vacuum

Breaker

Water Purveyor

Mfr Serial NumberSize Model Number

Phone

Assemby Addres

Permit No

Facility/Owner

Address

Owner Representative

Representative Address

On-Site Location

Water Meter No

City, State, Zip

ExistingNew

Serial #

Phone

Backflow Prevention Assembly

Test Report

Line Pressure:

Replacement

Protection Type: Service Type

Contact

Person to Contact

Primary Business or Service at this Location Is this a New Installation

Does this Assembly Replace Another

Purpose:

Final

Test

PHX

PSID

PSID

Air Inlet

CK Valve

Comments:

PSID

PSID

PSID

Opened at

Reduced Pressure

Repaired ReplacedShut Off Valves

Date FailedCertified Tester No.Initial Test (If Failed) By:

Repaired (If Necessary) By:

Final Test By:

Test Kit Serial

Date Repaired

Date Passed Test Kit Serial

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

Type

Leaked

Leaked Leaked Did Not Open

CLEANEDCLEANED CLEANED CLEANED

Air Inlet Disc

Airl Inlet Spring

Check Disc

Check Spring

Disc

Spring

Guide

Seat

Closed Tight

Disc

Spring

Guide

Seat

Closed Tight

Disc

Spring

Diaphragm

Seat

Closed Tight Closed Tight

Leaked

Rubber Kit Rubber Kit Rubber Kit Rubber Kit

#1 #2 #1 #2

City of Snoqualamish, WA

Owner of Property

Mailing Address

Device Address

Contact Person

Exact Location

Test Date

(Town) (Zip)(ST)

(Town) (ST) (Zip)

Size

Model No.Make

Serial No.

Reduced Pressure Backflow Preventer

Double Check Valve Assembly

Check Valve No. 1 Check Valve No. 2 Relief Valve

Pressure Vacuum Breaker

Check Valve Air Inlet

Initial Test Closed Tight

Leaked

________PSID

Opened at

Did Not Open

Repairs

Final Test

Condition of No. 2 Shutoff Valve

________PSID

Opened atClosed Tight

Leaked

________PSID Did Not Open

________PSID

Closed Tight Closed Tight Closed TightOpened at Opened at

________PSID________PSID ________PSID ________PSID________PSID

Closed Tight

Closed Tight Leaked

Leaked ________PSID

Inspection and Maintenance

Backflow Prevention Device

Report Form

1L

PASS

FAIL

Certification: On this date, the above device was tested per applicable codes and the required performance standards.

Permit Number

Test Type

Tester Name

Gauge No. Testing Firm

Tester Certification No.

Tester Signature:

Contact Signature:

Date:

Date:

Notes:

Line PSI

PVB

SVB

DCV

DDCV

RPBP

RPDA

PASS

Return Form By:

Test Report Due:

Test Gauge Used: Manufacturer/Model: SN:

Tester Name:

Company Address:

Tester Signature:

Company Name:

Phone #:

Certified Tester #:

The above is certified to be true at the time of testing Service Restored:

Remarks

Pressure Vacuum Breaker

Final Test

Initial Test

Repairs andMaterials Used

Test Date Reduced Pressure Principal Assembly

Double Check Valve Assembly Check Valve

Check Valve #1 Check Valve #2

Air Inlet

Relief Valve

Leaked

PSID

PSID

Leaked Leaked Did Not Open

Contact Name

Mfg:

Serial Number

Size: Model:

Map Page

PSID

Held at PSID

PSID

Held at PSIDOpened at

Did not Open

Closed Tight Closed Tight

Held at PSID

PSID

Held at PSID Opened at

Closed Tight Closed Tight

Existing New Replacement

Replaces SN#

PSID

Opened at Held at

Opened at Held at

Is the Assembly installed in accordance with manufacturers recommendations and/or local codes? Yes No

Water Turn Off Authorization: (Print) Time:

Yes No

Service Address

Location IDFacility Name

Phone:

Mailing Name

City/ST/Zip Telephone

Address 1

ST: Zip:

Assembly Information

Assembly Location Information

Zip:

Hazard Type

Equip Location

Property Information

Fail

Pass

Pass

PWS ID:(206) 555-1213

Type:

1M

Assembly ID

Calib/Accur Date:

I hereby certify that the Isolation/Shutoff Valves (SOV #1 and SOV #2) have been returned to the position in which they were found and that the test was done according to theprocedure shown above required by the Water District/Authority shown above; and the test readings are true and accurate to the best of my ability.

Protection

Domestic

Containment

by Isolation

Isolation

Containment

Assembly Serial #

Test Date/Time

Gauge Serial #

District Required Info

Tester Certification #

Date Certification Expires

Date Installed

Re-Test Results

Tight

Leak

Tight

Leak

Tightness Differential

Intial Test Results Repaired Cleaned

Tight

Leak

Tight

Leak

Tightness Differential

CK#1

CK#2

RV

Repaired

Air Inlet

Disc Spring Seat Other

Disc Spring Seat Other

Diaphragm Seat Other

Other

Air Inlet

Cleaned

Air Inlet

LIne PSI

Check Valve #1

CK#1: RPZ,DC,PVB,SVB

Check Valve #2

CK#2: RPZ,DC

Relief Valve

RV: RPZ

Buffer

RPZ

Air Inlet

PVB,SVB

Leak Tight

Leak Tight

SOV #1

SOV #2

Open Upon Arrival

Open Upon Arrival

Open Upon Departure

Open Upon Departure

Back Pressure Exists

Cause

Backflow Assembly Test and Maintenance Report(Please Print)

Assembly Test Results Pass Fail

Test #

Water District/Authority

Facility Name

Service Address

Mailing Address

Account: Contact Person

Contact Phone #

Owner

Company Name/Title

Mailing Address

Contact Person

Contact Phone #

Manager Contractor Other

Make: Size:Model:

PVB SVBDCRPZ AVBAir Gap Other

Location on Property

Stolen

New Installation

Replacement Assembly

(Only if Applicable - Include Previous Serial#)

Previous Assembly Serial #

Orientation Service

Irrigation

Fire

OtherHorizontal

Vertical Down

Vertical Up

Inlet Outlet

SEND TO:

Shutoff Valve #1

Shutoff Valve #2

Yes No

Assembly Concerns:

Incorrect Installation?

Incorrect Use?

Turn Off Date:

Turn Off Time:

CK#1 CK#2 RV CK#1 CK#2 RV

Turn On Date:

Turn On Time:

Test Procedure:

ABPA ASSE

Comments

Alarm Company/Fire Department Notified:

Person Notified:

Turn Off Date/Time:

Contacted By:

Turn On Date/Time:

Test Gauge Make: Test Gauge Model: Last Calibration Date:

Testing Company:

Tester Name:

Signature:

(Please Print)

(Tester)

Phone # Customer Name:(Please Print)

Phone #

Signature:(Customer)

(Submit a Clearly Printed Copy to the Water Purveyor)

(Please Print)

CO

(206) 555-1213

Poppet Bonnet

Make/Model Gauge #Calibration Date:

Tester Signature: Cert. No.:

I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.

PVBA/SVBA

Initial Test

DCVA / RPBA

CHECK VALVE #1 Air Inlet

Leaked Leaked

PSID

PSID

PSID

Opened at

Did not Open

Opened at

Failed

Passed

DCVA / RPBA

CHECK VALVE #2

RPBA

PSID#1 Check

Air Gap OK

Check Valve

PSIDHeld at

Leaked

Cleaned

Repaired

Test After

Repairs

New

Parts

and

Repairs

Contact Name Phone: FAX:

Make of Assembly: Serial Number Size:Model:

ExistingNew Install Replacement Old SN# Proper Installation? Yes No

Hazard Type PVBA AGDCVA RPBA Other

Service Address Zip:City:

Facility Name

Equip Location

Failed

Passed

Leaked Leaked PSID

PSID

PSID

PSID

Opened at Air Inlet

PSID#1 Check PSIDCheck Valv

Clean Replace Part Clean Replace Part Clean Replace Part

Authorized Tester:

Line PressureRemarks: PSI

Date:

Tester Name Printed: Testers Phone #( )

Repaired By: Date:

Final Test By: Cert. No.: Date:

Air Gap Inspection: Supply Pipe Diameter: Separation: FailPass""

TEST REPORTS MUST BE SUBMITTED IN ACCORDANCE WITH SEATTLE PUBLIC UTILITIES GUIDELINES.

Commercial: Residential:

PSID

Schedule Code

Return reports to:BACKFLOW PREVENTION ASSEMBLY

TEST REPORTCSB- Inspection Services

700 5th Ave, Suite #4900

P.O. Box 34018

Seattle, WA 98124-4018

Phone : (206) 684-3536

FAX : (206) 684-7585

Assembly ID

Annual Test & Maintenance Report for Backflow Prevention Assemblies

STATE OF OHIO

(All applicable fields must be filled out completely in order for test results to be accepted)

Facility Name:

Contact Person:

Address:

Phone No.

Make:

Model:

Size:

Serial Number:

Assembly Information

Meter Pit

Penthouse

Mechanical Room

Basement

Boiler Room

Protection Provided

Floor Number:

Room Number:

Installation Information

Containment Isolation

Double Check Valve Assembly

Initial

Test

Outer

Valve

1st

Check

Valve

2nd

Check

Valve

psid

psid

Pass

Fail

Pass

Fail

Pass

Fail

Reduced Pressure Assembly

1st

Check Valve

Relief Valve

Opening Point

2nd

Check Valve

psid

psid

Pass

Fail

Pass

Fail

Pass

Fail

Outlet Valve Pass Fail

Pass

Fail

Pass

Fail

Pressure Vacuum Breaker

Air Inlet Valve

Check Valve

psid

psid

Repairs &

Materials

Used

Date

Double Check Valve Assembly

Re-Test

After

Repairs

Outer

Valve

1st

Check

Valve

2nd

Check

Valve

psid

psid

Pass

Fail

Pass

Fail

Pass

Fail

Reduced Pressure Assembly

1st

Check Valve

Relief Valve

Opening Point

2nd

Check Valve

psid

psid

Pass

Fail

Pass

Fail

Pass

Fail

Outlet Valve Pass Fail

Pass

Fail

Pass

Fail

Pressure Vacuum Breaker

Air Inlet Valve

Check Valve

psid

psid

Date

TESTER CERTIFICATION I certify that the above data is correct and that the backflow prevention device is in proper working

condition.

Tester Name (Printed)

Company Name

Signature

OH Cert. No.

Phone No.

DateContractor No.

FACILITY

CERTIFICATION

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 bypassed, made inoperative or

removed without proper authorization. I further certify that I have the authority and responsibility to ensure the

above.

Owner/Officer (Printed)

Title

Signature Phone No.

Date

Return Original To: Email:

All applicable fields must be filled out completely in order for test results to be accepted

Phone:

Fax:

(206) 555-1213

(206) 555-2121

Make/Model: Gauge #Calibration Date:

Tester Signature: Cert. No.:

PVBA/SVBA

Initial Test

DCVA / RPBA

CHECK VALVE #1 Air Inlet

Leaked Leaked

PSID

PSID

PSID

Opened at

Did not Open

Opened at

Failed

Passed

DCVA / RPBA

CHECK VALVE #2

RPBA

PSID#1 Check

Air Gap OK

Check Valve

PSIDHeld at

Leaked

Cleaned

Repaired

Test After

Repairs

New

Parts

and

Repairs

Yes No

City of Snoqualamish

1345 Washougal Blv.

Snoqualamish, WA

98215

(206) 555-2121

Failed

Passed

Leaked Leaked PSID

PSID

PSID

PSID

Opened at Air Inlet

PSID#1 Check PSIDCheck Valve

Clean Replace Part Clean Replace Part Clean Replace Part

Line PressureRemarks: PSI

Date:

Tester Name Printed: Testers Phone #( )

Repaired By: Date:

Final Test By: Cert. No.: Date:

Air Gap Inspection: Supply Pipe Diameter: Separation: FailPass""

PSID

FAX:

Return reports to:BACKFLOW PREVENTION

ASSEMBLY

TEST REPORT

1R

Contact Name Phone: FAX:

Make of Assembly: Serial Number Size:Model:

ExistingNew Install Replacement Old SN# Proper Installation?

Hazard Type PVBA AGDCVA RPBA Other

Service Address Zip:City:

Facility Name

Equip Location

Commercial: Residential:

Authorized Tester:Schedule CodeAssembly ID

Mailing Address

0

BACKFLOW ASSEMBLY TEST FORM.

RETURN ORIGINAL FORM ONLY .

Service Address

Contact Name

Install Date

Mfr

SN

Size

Type

Model

Return Report By:

Schedule Code

Location ID

Map Page

Permit Num

Hazard Type Haz. Level

Assembly ID

Meter #

Facility Name

Equip Location

Protection Type

#2

Assembly Info

OFFICIAL USE ONLY

TEST RESULT PASS FAIL

COMMENTS

CERTIFICATION OF FIELD TEST REPORT

The undersigned certify this report is true and accurate and the backflow prevention assembly detailed above was

tested this day, in accordance with all rules and regulations promulgated by the Authority Having Jurisdiction (AHJ).

Initial Test By (Signature) Tester Number MO DAY YR

Name (Please Print)

Repaired By Tester Number MO DAY YR

Final Test By (Signature) Tester Number MO DAY YR

Return Reports To:

Service Type

(Replacement/Correction

City of Snoqualamish, WA

Backflow Prevention Program

Robert Mum

City of Snoqualamish

1345 Washougal Blv.

Snoqualamish, WA

98215

PH: (206) 555-1213

FAX: (206) 555-2121