Backflow Report

CITY OF:

INVOICE NUMBER:

MANAGER APPROVAL:

BACKFLOW PREVENTION ASSEMBLY FIELD TEST REPORT

DomesticIrrigationFire

DATE OF TEST:

NAME OF PREMISE:

STREET ADDRESS:

Device {{rep-1_index}}

LOCATION OF DEVICE:

TYPE OF DEVICE: RPD.C.PVBOther

SIZE:

PERMIT NUMBER:

MANUFACTURER:

METER NUMBER:

MODEL NUMBER:

SERIAL NUMBER:

PRESSURE VACUUM BREAKER

REDUCED PRESSURE

INITIAL TEST: AIR INLET OPENEDAIR INLET DID NOT OPEN

LBS AIR INLET OPENED AT:

CHECK VALVE: LEAKEDCLOSED

HELD AT (PSI):

LINE PRESSURE:

REMARKS:

REDUCED PRESSURE ZONE ASSEMBLY

Check #1

LEAKEDCLOSED

PASSEDFAILED

PSI:

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: PSI:

PASSEDFAILED

Relief

Opened at PSI:

PASSEDFAILED

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: Closed at PSI:

PASSEDFAILED

Check #2

LEAKEDCLOSED

PASSEDFAILED

PSI:

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: PSI:

PASSEDFAILED

REMARKS:

DOUBLE CHECK ASSEMBLY

Check #1

LEAKEDCLOSED

PASSEDFAILED

PSI:

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: PSI:

PASSEDFAILED

Relief

Opened at PSI:

PASSEDFAILED

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: Closed at PSI:

PASSEDFAILED

Check #2

LEAKEDCLOSED

PASSEDFAILED

PSI:

Cleaned OnlyReplaced

PASSEDFAILED

Retest results: PSI:

PASSEDFAILED

REMARKS:

I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE UNIT.

CERTIFIED TESTING COMPANY

BACKFLOW INSPECTION & REPAIR
1533 SW 1st WAY #F-15
DEERFIELD BEACH, FL 33441

INITIAL TEST BY:

TESTER SIGNATURE:

CERTIFIED TESTER NO.*:

EXP. DATE:

TEST EQUIPMENT USED:

MODEL NUMBER:

SERIAL NUMBER:

EXP. DATE:

TESTER SIGNATURE:

CERTIFIED TESTER NO.*:

EXP. DATE:

TEST EQUIPMENT USED:

MODEL NUMBER:

SERIAL NUMBER:

EXP. DATE:

EMAIL (to receive copy of submission)*:

Invoice Number/Job Name:

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