BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE …

1 BACKFLOW P REVENTION ASSEMBLY TEST & MAINTENANCE REPORT Customer Name: Mail ing Address: City State Zip: SERVIC E LOCATIO N: ASSEMBLY LOCATIO N: MFR: MODEL: SERIAL # TYPE: LINE PRESSURE: INI TIAL TEST CHECK VALVE 1 HELD AT ____ PVB _____ RP PRESS DP __ LEAKED _ _____ CHECK VALVE 2 HELD AT _ ____ . _____ RP TIGHT _ _____ LEAKED _ _____ RELIEF VALVE __ PSI DID NOT OPEN _____ AIR INLET OPEN __ PSI DID NOT OPEN _____ REPAIRS CLEANED _____ REPLACED _____ DISC _____ SPRING _____ GUIDE _____ HINGE PIN _____ SEAT _ ____ MODULE _____ OTHER _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ SPRING _ ____ GUIDE _____ HINGE PIN _____ SEAT _ ____ MODULE _____ OTHER _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ DIAPHRAGM _ ____ FLOAT _ ____ SPRING _ ____ OTHER _____ O-RING(S) _____ MODULE _____ DESCRIBE: CLEANED _ ____ REPLACED _ ____ DISC _____ DIAPHRAGM _ ____ FLOAT _ ____ SPRING _ ____ OTHER _____ DESCRIBE: FINAL TEST CLOSED TIGHT _ __ CLOSED TIGHT _ __ OPENED AT __ PSI OPENED AT __ PSI COMMENTS: THE A BOVE R EPORT IS CERTIFIED TO B E T RUE.

2 PASS FAIL INITIA L TEST ( SIG NATURE) PRI NT NAME T ESTER CERT # DATE FINAL TEST A FTER REPAIRS P RI NT NAME TESTER CERT # DATE __ ____ ___ _____ ___ ___ ____ ____ ___ _____ ___ ___ ____ ____ ___ _____ ___ _____ ____ ___ _____ ___ ___ _ TESTER S COMPANY NAME TESTER S PHONE NUMBER ONLY C ALIFORNIA DEPT. OF PUBLIC HEALTH APPROVED A SSEMBLI ES, SHUT-OFF V ALVES, TEST COCKS, AND PARTS A RE A UTHORIZED FOR USE BY T HIS DEPARTMENT. TEST REPORTS MUST BE COMPLETED IN INK. DO NOT REPLACE ASSEMBLY WITHOUT CONTACTING ENVIRONMENTAL QUALIT Y DEPARTMENT. PLEASE R ETURN C OMPLETED FORM TO RESPECTIVE DIS TRIC T OFFICE (if unsure, call 1-800-999-4033): Central D istr ict: 1230 5 B urke Street Ste.

3 1, Santa Fe Springs C A 9 06 70 Coasta l Distr ict: 1140 Lo s Olivos A ve. , L os O sos C A 93 402 Mountai n Des ert Distr ict: 1 36 08 Hitt Road , Appl e V al ley C A 9 23 08 Sou thwes t Distr ict: 14 401 Chadron Ave., Hawthorne CA 9 02 50 Foo th ill D istr ict: 401 Sou th San Di mas Canyon Roa d, San Di mas CA 917 73 Oran ge C ou nty Di str ict: 1920 W Corporate Way, Anaheim CA 92801 Northern Di str ict: 3005 Gold Canal Drive, Rancho Cordova, CA 95670