Backflow Prevention Assembly Test Report
Download a blank fillable Backflow Prevention Assembly Test Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Backflow Prevention Assembly Test Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Print Form
TALQUIN ELECTRIC COOPERATIVE, INC.
4852 Woodlane Circle, Tallahassee, FL 32303
Phone: 850-562-2115 Fax: 850-562-2234
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
Account #:
TEC METER NUMBER
Name of Premise:
Commercial
Residential
Service Address:
Contact Person:
Phone #:
Fax #:
Location of Assembly:
New Installation
Existing
Replacement
Old Assembly Serial No.:
Type of Assembly:
RP
DC
DDC
PVB
Other:
Make:
Model:
Size:
Serial No.:
Installed to specifications: Yes
No
Riser Material:
Clearance:
inches
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Air Inlet
Check Valve
Relief Valve
Check Valve #1
Check Valve #2
Leaked
Leaked
Initial
Closed Tight
Closed Tight
Did not Open
Did not Open
Leaked
Test
Held at ________ psid
Held at ________ psid
Opened at _____ psid
Opened at ______ psid
Held at _______ psid
Repairs
Cleaned
Cleaned
Cleaned
Cleaned
Cleaned
Replaced
Replaced
Replaced
Replaced
Replaced
Details
Test
Held at ________ psid
Held at ________ psid
After
Opened at _____ psid
Opened at _____ psid
Held at _______ psid
Closed Tight
Closed Tight
Repair
Note: All repairs shall be completed within TEN (10) working days.
This Assembly: PASSED
FAILED
Remarks:
I hereby certify that this data is accurate and reflects the proper operation and maintenance of this assembly.
Testers Signature:
Cert. No.:
Date:
Testers Name Printed:
Testers Phone #:
Repaired By:
Date:
Final Test By:
Cert. No.:
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business