BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE …

1 BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE report Tucson Water must receive a correct BACKFLOW PREVENTION ASSEMBLY Test report by the compliance due date. Failure to comply with all requirements will result in assessment of compliance fees and discontinuance of water service. Responsibility for the BACKFLOW PREVENTION ASSEMBLY test is that of the water service's financially responsible party. Customer: _____ Phone No.: _____ Customer: _____ Phone No.: _____ Service Address: _____ Water Meter No.: _____ Service Address: _____ Water Meter No.: _____ BPA Mfg.: _____ BPA Model: _____ BPA Sz.: _____ BPA Serial No.

2 : _____ BPA Mfg.: _____ BPA Model: _____ BPA Sz.: _____ BPA Serial No.: _____ _____ _____ Name of person authorizing BPA test: Phone No.: Name of person authorizing BPA test: Phone No.: Tester Tester Comments Comments X _____ _____ _____ _____ X _____ _____ _____ _____ Tester s Signature Tester ID# Test Date Equip ID# Tester s Signature Tester ID# Test Date Equip ID# FIRST TEST DC/RP Check Valve #1 Held @_____psid Leaked _____ BPA Replacement Information DC/RP Check Valve #1 Cleaned Replaced _____ Disc _____ _____ Spring _____ _____ Guide _____ _____ Seat _____ _____ Module _____ _____ O Ring _____ DC/RP Check Valve #2 Held @_____psid Leaked _____

3 Closed Tight _____ RP Relief Valve Opened @_____psid Leaked _____ Did Not Open _____PVB / SVB Air Inlet Opened @_____psid Did Not Open _____ Check Valve Held @ _____ psid Leaked _____AIR GAP Size of Pipe Opening _____ Distance above Flood Rim _____BPA Serial # BPA Make BPA Model BPA Size PVB / SVB Cleaned Replaced _____ Disc _____ _____ Spring _____ _____ Guide _____ _____ Seat _____ _____ Module _____ _____ O Ring _____ _____ Diaphragm _____ Relief Valve Cleaned Replaced _____ Disc _____ _____ Spring _____ _____ Guide _____ _____ Seat _____ _____ Module _____ _____ O Ring _____ _____ Diaphragm _____ DC/RP Check Valve #2 Cleaned Replaced _____ Disc _____ _____ Spring _____ _____ Guide _____ _____ Seat _____ _____ Module _____ _____ O Ring _____ Permit# REPAIRS X_____ _____ X_____ _____ Repairer s Signature Repair Date Repairer s Signature Repair Date PVB / SVB Air Inlet Opened @_____psid Check Valve Held @ _____ psid Relief Valve Opened @_____psid DC/RP Check Valve #2 Held @_____psid Closed Tight _____ DC/RP Check Valve #1 Held @_____psid RE TEST X _____ _____ _____ _____ X _____ _____ _____

4 _____ Tester s Signature Tester ID# Test Date Equip ID# Tester s Signature Tester ID# Test Date Equip ID# Test reports must be entered online into the iBAK System within five days of the test, and before the due date. Test reports must be entered online into the iBAK System within five days of the test, and before the due date. Remember to give the customer a copy of this test report . Remember to give the customer a copy of this test report .