BACKFLOW PREVENTION ASSEMBLY TEST RE

1 BACKFLOW PREVENTION ASSEMBLY TEST TEST DATE: _____ COMMERCIAL RESIDENTIAL NAME OF PREMISE: _____SERVICE ADDRESS: CITY ZIP: CONTACT PERSON: _____ LOCATION OF ASSEMBLY : _____DOMESTIC FIRE LINE FIRE LINE BYPASS LAWN SPRINKLER OTHER: _____ DCVA RPBA PVBA DCDA OTHER: _____NEW INSTALLATION EXISTING REPLACEMENT OLD ASSEMBLY SERIAL NUMBER: MAKE OF ASSEMBLY : MODEL: SERIAL NO.: SIZE: INITIAL TEST PASSED FAILED DCVA/RPBACHECK VALVE OUTLET VALVE PASS FAIL LEAKED CLOSED TIGHT PSID DCVA/RPBACHECK VALVE LEAKED CLOSED TIGHT PSID RPBA OUTLET VALVEPASS FAIL OPENED AT PSID#1 CHECK PSIDAIR GAP OK?

2 _____ PVBA AIR INLETOPENED AT PSID DID NOT OPEN REPAIRS CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVEHELD AT PSIDLEAKED CLEANED REPAIRED TEST AFTER REPAIRSCLOSED TIGHT PSIDCLOSED TIGHT PSIDOPENED AT PSID#1 CHECK PSIDAIR INLET PSIDCHK VALVE PSIDAIR GAP INSPECTION: Required minimum air gap separation provided?

3 Yes No REMARKS: LINE PRESSURE TESTER S SIGNATURE CERT. NO. EXP. DATE _____TESTER S NAME PRINTED COMPANY NAME: PHONE NUMBER: (_____)_____ FAX NUMBER: (_____)_____GAGE CALIBRATION DATE _____/_____/_____ WATER SERVICE RESTORED YES NO MEDINA COUNTY SANITARY ENGINEERS PHONE # 330-764-8329 or 330-764-8345 FAX # 330-764-8589 Please return report to: Medina County Sanitary Engineers BACKFLOW PREVENTION Program Box 542 Medina, OH 44258