Backflow Prevention Assembly Test Data And Maintenance Report Form
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1StLCO Form: Test Rpt 0305b
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
Customer:
Mailing Address:
City and State:
Zip Code
Address of Location of Back-Flow Device:
Describe physical location of Back-Flow Device:
Manufacturer:
Model:
Size:
Serial Number:
Type Of Device: ________ Air Gap
_______ DC _______ RP ________ PVB
Application :
(from MO part 10.CSR 11.010):
Device protected from:
Air Gap (2 x Supply Diameter)
__________ Containment
Hazard Class _________
_____ Freezing
Supply ________ in
_______ Pass
__________ Isolation
Hazard Item
_________
_____ Flooding
Gap ___________in
_______ Fail
Date Of Test
Describe the Equipment that the Back-Flow Device Services
Height Off Floor
________________(FT/IN)
Permit Information
Installation Status
Type Of System
Number_________________________
New_____
Existing_______
Fire Suppression _____ Process Piping ____
Contractor____________________________
Is the assembly properly tagged?
Lawn Irrigation ______
Plumbing _______
Permit Date___________________________
Yes______
No________
Other _______________________________
INITIAL TEST_____ FINAL TEST______
PASSED
FAILED
INITIAL TEST____ FINAL TEST_____ PASSED
FAILED
Reduced Pressure Assembly:
Double Check Valve Assembly:
st
1
CHECK held in direction of flow
st
1
CHECK held in direction of flow
_____ PSID (5 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
RELIEF VALVE opened at
nd
2
CHECK held backpressure
________
_______
_____ PSID (2 PSID or more)
________
_______
No. 2 Shut-off Valve leak tight
________
_______
st
DIFFERENCE (1
check-relief)
nd
2
CHECK held in direction of flow
_____ PSID (3 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
nd
2
CHECK held backpressure
________
_______
_______________________________________________________
No. 2 Shut-off Valve leak tight
________
_______
FINAL TEST _______ PASSED _______ FAILED
OPTIONAL TEST
Pressure Vacuum Breaker Assembly:
Relief Valve (exercised to open Position)
________
_______
Test #1 Shutoff Valve
___________________________________________________________
- held pressure tight.
________
_______
Comments:
Test CHECK VALVE held in direction
___________________________________________________________
of flow ________ PSID (1 PSID or more)
________
_______
___________________________________________________________
Test AIR INLET VALVE to open
___________________________________________________________
________ PSID (1 PSID or more)
________
_______
PVB may not be repaired, must be replaced
___________________________________________________________
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
Tested By: (Print name and provide Signature)
Repaired By: (Print name and provide Signature)
Company
Final Test By: (Print name and provide Signature)
Certification Number And Expiration Date
Owner Or Owner’s Representative
Date
1. This form is to be used and sent to St. Louis County for a failed test as well as a passed test.
Do not use one form for both the failed and passed test. Use a separate form for each.
2. This form must be filed within 30 days of test per state regulations and St. Louis County Ordinance.
3. Tester must sign this form.
C:\Documents and Settings\pw0l0b.000\Desktop\0305b Backflow Form.doc
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