Backflow Prevention Device Inspection And Maintenance Report Form

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BACKFLOW PREVENTION DEVICE
Initial
INSPECTION AND MAINTENANCE
Annual (DCVA or PVB)
REPORT FORM
Semi-annual (RPBP)
(Print Clearly)
_________________________________________________________
PWS ID #:
_____/______/______/______/______/______/______
Public Water System Name
________________________________________________________
________________________________________________________
Facility Address
Facility Name
_________________________________________________________
, MA
Facility Owner/Responsible Party
_______________________________________
_____________
City/Town
Zip
______________________________________, ______ ___________
City/Town
State Zip
________________________________________________________
Mailing Address
(_________)__________-________________ ext. ________________
Phone #
________________________________________________________
Contact Person
Exact location of cross-connection protected by device/
Cross-connection Info: ID #
assembly
:
__________________________
______________________________________
Device Info:
RPBP
DCVA
PVB
_____________________________________________
__________________________
____________________
Make
Model
_
Yes
No
Supplemental protection at meter required:
Material:
Bronze
Iron
Stainless Steel
________________”
______________
Size
Serial #
Shutoff Valve Type:
Ball
NRS
OS&Y
Butterfly
Other
_________________________________________
:
Yes
No
By-pass
Auxiliary Supply
__________________________________________
:
Installation:
Vertically
Horizontally
Installation required by
State
Local
Yes
No
Yes
Are repair parts available on site?
Is device installed on fire protec. system?
No
Test Kit Information
Make
Model
Serial #
Last Calibration
_______________
_______________
_________
____/____/____
RPBP
PVB
DCVA
Relief Valve
st
nd
1
Check
2
Check
Air Inlet
Check Valve
Open at ____
Closed Tight
Closed Tight
Test Date
psid
Open at
_____
psid
Held at ______psid
Held at ______psid
_____psid
______/______/______
Did not pen
Leaked
Leaked
Leaked
nd
2
Shutoff Valve
Closed Tight
Leaked
Test Result
*
PASS
FAIL
I hereby certified that I have personally tested the above backflow prevention device/assembly in accordance with
the method and procedure that I was trained, and the test result is true and shows that the device/assembly is in
proper operating condition. (Signatures required)
Backflow Device Test Conducted by a MassDEP Certified Backflow Prevention Device Tester
___________________________ ______________
____/____/____
________________________
(_____)_____-_________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by a Facility Owner/Representative
________________________________ _______________________ ___________________________
____/____/____
Facility Owner/Representative Name (Print)
Title
Signature
*
If a backflow prevention device failed a test, the following steps are required by the Massachusetts Drinking Water Regulations:
The owner of the device must obtain the service of a Massachusetts licensed plumber or a Massachusetts licensed fire sprinkler

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