Backflow Prevention Assembly Test Report Form
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1Backflow Prevention Assembly Test Report
Service Address
Location_____________________________________________________________________
Check if Correct
Corrections
_______________
______________
Serial #:
_______________
______________
Manufacturer:
Mailing Phone ____________________
Mailing Address
_______________
______________
Model:
_______________
______________
Type:
_______________
______________
Size:
_______________
______________
Orientation:
Hazard: ____________
Meter#: ____________
_______________
______________
Premise ID:_________
SPID:______________
Protection:
Test Due No
Removed
Commercial
Existing
Construction
Domestic
Irrigation
Residential
Fire
Later than:
Replaced
Industrial
New
Reduced Pressure Principle Assembly
Air Gap
Required Separation
Yes
No
Double Check Valve Assembly
PVB/SVB
Check Valve #1
Check Valve #2
Relief Valve
Air Inlet
Check Valve
Initial Test
Did not open
Leaked
Leaked
Did not open
Leak
Date ________
Closed Tight
Opened at ____ PSID
Closed Tight
Opened at ____ PSID
Held at ____ PSID
Time________
Held at______PSID
Held at______PSID
Repairs
Cleaned
Cleaned
Cleaned
Cleaned
Cleaned
Date ________
Replaced
Replaced
Replaced
Replaced
Replaced
Time________
Rubber Kit
Rubber Kit
Rubber Kit
Rubber Kit
Rubber Kit
CV Assembly
CV Assembly
RV Assembly
CV Assembly
Disc
Disc
Disc
Disc
Disc
O-rings
O-rings
Diaphram(s)
Spring
Spring
Seat
Seat
Seat
Retainer
Retainer
Spring
Spring
Spring
Guide
Guide
Stemguide
Stemguide
Guide
O-rings
O-rings
Retainer
Retainer
O-rings
Other
Other
Lock Nuts
Lock Nuts
Other
Other
Other
Final Test
Closed Tight
Closed Tight
Held at ____ PSID
Date ________
Held at ____ PSID
Held at ____ PSID
Opened at ____ PSID
Opened at ____ PSID
Time________
Notify us if failed assemblies cannot be repaired within three days.
Yes No
Proper Installation
Comments:
RV Exercised
____________________________________________________________________________________________
#2 Shutoff Closed
____________________________________________________________________________________________
Service Restored
I certify all information on this report is true and accurate, acknowledging that incomplete reports will not be
accepted.
Line Pressure _______________
Tester______________________________________________________________________________________
Meter Reading ______________
Certification #_____________________________________ Phone ____________________________________
Passed
Failed
Test Kit Serial # ___________________________________ Calibration Date ____________________________
Signature ___________________________________________________________________________________
Kansas City Water Services
Return completed
2409 E. 18th St.
Test Report to:
Kansas City, MO 64127
Phone: 816-513-4795 Fax: 816-513-4798
Email:
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