Backflow Preventer Test And Maintenance Report Form
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Charlotte Water
BACKFLOW PREVENTER TEST AND MAINTENANCE REPORT
CUSTOMER:______________________________________________________________________________________________
ADDRESS OF PROPERTY:__________________________________________________________________________________
MAILING ADDRESS:_______________________________________________________________________________________
METER NUMBER or ERT#:________________________________SERVICE NUMBER:_________________________________
TYPE OF SERVICE:
TYPE OF ASSEMBLY:
TYPE OF TEST
[ ] DOM.
[ ] IRRIG.
[ ] RP
[ ] Containment (at meter)
[ ] F.L.
[ ] DC
[ ] Isolation (at branch)
[ ] COMBINATION (DOM. & F.L.)
[ ] PVB
ASSEMBLY INFORMATION
_______
_____________________
____________________
_____________________
Size
Manufacturer
Model
Serial No
LOCATION OF ASSEMBLY:__________________________________________________________________________
Line Pressure: _______ PSI
(#1or #2 Testcock)
CHECK VALVE #1
RELIEF VALVE
CHECK VALVE #2
PRESSURE VACUUM
BREAKER
[ ] LEAKED
OPENED AT
[ ] LEAKED
AIR INLET OPENED
[ ] CLOSED TIGHT
________ PSID
[ ] CLOSED TIGHT
AT________PSID
DIDN'T OPEN
[ ]
DIFF. PRESSURE
DID NOT OPEN
[ ]
DIFF. PRESSURE
CHECK VALVE:
ACROSS CHECK
ACROSS CHECK
LEAKED
[ ]
VALVE _______ PSID
VALVE _______ PSID
HELD AT_____PSID
BUFFER______ PSI
[ ] CLEANED ONLY
[ ] CLEANED ONLY
[ ] CLEANED ONLY
[ ] CLEANED ONLY
REPLACED:
REPLACED:
REPLACED:
REPLACED:
RUBBER KIT
[ ]
RUBBER KIT
[ ]
RUBBER KIT
[ ]
RUBBER KIT
[ ]
CV ASSEMBLY
[ ]
CV ASSEMBLY
[ ]
CV ASSEMBLY
[ ]
CV ASSEMBLY
[ ]
OR
OR
OR
OR
OTHER
[ ]
OTHER
[ ]
OTHER
[ ]
OTHER
[ ]
List:
List:
List:
List:
_________________________
______________________
_________________________
_____________________
_________________________
______________________
_________________________
_____________________
[ ] CLOSED TIGHT
OPENED AT
[ ] CLOSED TIGHT
AIR INLET______PSID
_________ PSID
DIFF. PRESSURE
DIFF. PRESSURE
CHECK VALVE
ACROSS CHECK
ACROSS CHECK
BUFFER______ PSI
VALVE ________ PSID
VALVE ________ PSID
______ PSID
SHUT – OFF #1
SHUT-OFF#2
Leaked (___) Held Tight (___)
Leaked (___) Held Tight (___)
Assembly PASSED (___) OR FAILED (___)
NOTE: ALL REPAIRS MUST BE COMPLETED WITHIN (10) DAYS.
REMARKS:_______________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
TEST KIT: MANUFACTURER: ______________________ MODEL: ________________ SERIAL NO.: _____________________
I HEREBY CERTIFY THAT THIS COMPLETED BACKFLOW PREVENTER TEST AND MAINTENANCE REPORT ACCURATELY REFLECTS
OPERATION AND CONDITIONS OF THE SPECIFIED ASSEMBLY AT THE TIME OF THIS TEST.
TESTER
:___________________________________________________ CERT.NO.:___________________________
(Signature)
TESTER
:__________________________________________ PHONE #: __________________________________
(Printed Name)
DATE OF TEST:_____________________ TIME:___________________
Mail to: Charlotte Water
Attn: Backflow Prevention
Or e-mail to:
backflowtests@charlottenc.gov
Or fax to: 704-632-8392
5100 Brookshire Blvd.
Charlotte, NC 28216
Operated by City of Charlotte
Revised 1/15/2015
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