Backflow Assembly Test Report Form
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1City of Post Falls Water Division 2002 W. Seltice Way Post Falls, ID 83854
Internet:
Email:
Office: (208) 777-9857
.
Customer Name: _____________________________________________________
Date: _____ / _____ 20
Street Address: __________________________________________________________________, ID ___________
(assembly premises)
Location of Assembly: ___________________________________ Hazard Isolated: _________________________
Make: ________________ Model: _________________ Serial Number: _____________________ Size: ______
Yes ____ No ____
Line pressure: __________ PSI
RPBA/RPDA DCVA/DCDA HORIZONTAL SET?
Check valve #1
Check valve #2
Relief valve
PVB/SVB
Shut off Valves
#1
#2
Held at _____
Held at _____
Opened at
Air Inlet
Opened
Initial
PSI
PSI
_____ PSI
at _____ PSI
Closed tight
Test
Closed Tight
Closed Tight
Opened Fully
Did not open
Leaked
Leaked
Did not open
Leaked
Check held
at _____ PSI
Leaked
CLEANED
CLEANED
CLEANED
CLEANED
CLEANED
REPLACED:
REPLACED:
REPLACED:
REPLACED:
Disc
Disc
Disc
Poppet / Float
REPLACED
Spring
Spring
Spring
Air Inlet Spring
Guide
Guide
Diaphragm
Check Disc
Seat
Seat
Seat
Check Spring
Hinge Pin
Hinge Pin
O-Ring(s)
O-Ring(s)
Module
Module
Module
Guide
_______
________
________
____________
“OTHER”
EXISTING ASSEMBLY
REPLACED ASSEMBLY
NOTES:
NEW INSTALLATION
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________REPLACED ASSEMBLY’S SER. #:____________________________
Opened at
________PSI
________PSI
Air Inlet _________ PSI
Shut Off
Final
Valves
#1
#2
Test
Closed Tight
Closed Tight
_______PSI
CK Valve ________ PSI
Closed Tight
Note: Report must be submitted within ten (10) days of test. Any backflow prevention assembly left in a failed (non-passing)
condition posing a potential threat to the potable water supply must be reported to the purveyor within 24 hours!
Tester’s Name: ______________________________ (print) I. B. O. L. License #: ____________ Gauge #:_________________
B.A.T. Tag attached
Final Backflow Assembly Test Results:
PASSED
FAILED
WATER SERVICE RESTORED
“I certify the assembly was tested according to U. S. C. test protocol and the above report is certified to be true.”
ACKNOWLEDGED BY: ________________________________________________ (Tester’s Signature)
Employer/company name: _______________________________________________ Phone #: ________________
Employer and/or Tester’s email address: ____________________________________________________________
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