BACKFLOW PREVENTION ASSEMBLY FIELD TEST FORM

1 RPDA RP RPDA IIINITIAL TESTC heck Valve 1 Check Valve 2 Relief ValveCheck Valve 1 Check Valve 2 Relief ValveBypass Check_____ PSID Leaked Closed Tight Leaked _____ PSIDDid Not Open_____ PSID Leaked Closed Tight Leaked _____ PSIDDid Not Open_____ PSID LeakedREPAIRDETAILS Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned ReplacedFINAL TEST_____ PSID Leaked Closed Tight Leaked_____ PSIDDid Not Open_____ PSID Leaked Closed Tight Leaked_____ PSIDDid Not Open_____ PSID Leaked4 DCDA DC DCDA IIINITIAL TESTC heck Valve 1 Check Valve 2 Check Valve 1 Check Valve 2 Bypass CheckLeaked _____ PSID Leaked _____ PSID Leaked _____ PSID Leaked _____ PSID Leaked _____ PSID REPAIRDETAILS Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned Replaced Cleaned ReplacedFINAL TESTL eaked _____ PSID Leaked _____ PSID Leaked _____ PSID Leaked _____ PSID Leaked _____ PSID 3 Mainline Mfr.

2 ModelSizeOrientationSerial NumberINITIAL TESTDate _____Time _____Certified Tester Name (Print) _____Tester Signature _____ Pass FailREPAIRDETAILSDate _____Time _____Certified Tester Name (Print) _____Tester Signature _____FINAL TESTDate _____Time _____Certified Tester Name (Print) _____Tester Signature _____ Pass FailService Name/Address: Service Number:Owner Name/Address: RP DC PVB SVB DCDA RPDA DCDA II RPDA IIAssembly Location:1 COMMENTS:65 PVB SVBINITIAL TESTAir Inlet _____ PSIDDid not OpenOpened Fully? Yes NoCheck Valve _____ PSIDL eakedREPAIRDETAILS Cleaned ReplacedFINALTESTAir Inlet _____ PSIDDid not OpenOpened Fully?

3 Yes NoCheck Valve _____ PSIDL eaked2 Bypass Water Meter Reading Before Test: _____ After Test: _____ Onsite contact acknowledged _____ Bypass Mfr: ModelSizeOrientationSerial NumberBACKFLOW PREVENTION ASSEMBLY FIELD TEST FORMMAINLINEBYPASSMAINLINEBYPASS