HomeMy WebLinkAboutM_Backflow Test Fire Service_20220803_v1BACKFLOW PREVENTION ASSEMBLY TEST REPORT
NAME OF PREMISE Commercial Residential
SERVICE ADDRESS
CUSTOMER PRINTED NAME PHONE FAX
LOCATION OF ASSEMBLY
TYPE OF HAZARD ISOLATED DCVA RPBA OTHER
NEW INSTALLATION EXISTING REPLACEMENT LINE PRESSURE:PSI
MAKE OF ASSEMBLY MODEL SERIAL #SIZE ”
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes No PROPER INSTALATION? YES NO
INITIAL TEST
PASSED
FAILED
DCVA / RPBA
CHECK VALVE #1
DCVA / RPBA
CHECK VALVE #2 RPBA PVBA / SVBA
LEAKED
CLOSED TIGHT
PSID
LEAKED
CLOSED TIGHT
PSID
OPENED AT PSID AIR INLET
OPENED AT PSID#1 CHECK PSID
AIRGAP OK? DID NOT OPEN
NEW PARTS
AND
REPAIRS
CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVE
HELD AT PSID
LEAKED
CLEANED
REPAIRED
TEST AFTER
REPAIRS
PASSED
FAILED
CLOSED TIGHT CLOSED TIGHT OPENED AT PSID AIR INLET PSID
PSID PSID #1 CHECK PSID CHECK VALVE PSID
Detector Meter Reading:
LINE PRESSURE PSI CONFINED SPACE? YES NO
REMARKS:
TESTER’S SIGNATURE:CERT #:DATE:
TESTER’S NAME PRINTED:TESTERS PHONE #
REPAIRED BY:LIC. #:DATE:
FINAL TEST BY:CERT #:DATE:
CUSTOMER’S SIGNATURE:DATE:
CALIBRATION DATE:GAUGE #:SERVICE RESTORED? YES NO
FIRE PROTECTION DIVISION
6WK6WUHHW.HQW:$
3K)D[
$5&+(,
'5