HomeMy WebLinkAboutM_Backflow report domestic vault_20250304_v1Make/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
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
Clean Replace Part Clean Replace Part Clean Replace Part
Authorized Tester:
Line PressureRemarks:
Confined Space
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 REPORT
Assembly ID
SPU_Backflow@seattle.gov