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BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM

BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM Please fill this form out COMPLETELY and return to: Rochester Public Utilities 4000 East River Road NE Rochester, MN 55906 Email completed form to: Attention: Business Services Version 2 5/7/14 MANUFACTURER MODEL SIZE SERIAL # NAME OF BUSINESS ADDRESS (street, city, zip) LOCATION OF DEVICE IN BUILDING TYPE OF BACKFLOW ASSEMBLY : RPZ DCV New Install Existing Device Replacement Old ASSEMBLY Serial #:_____ CHECK VALVE #1 (RPZ/DCV) CHECK VALVE #2 (RPZ/DCV) RELIEF VALVE (RPZ) INITIAL TEST 1.

BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM Please fill this form out COMPLETELY and return to: Rochester Public Utilities 4000 East River Road NE

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