Air Gap Verification Form - Denver Water
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1
2AIR GAP VERIFICATION
FOR MOBILE APPLICATIONS
A completed Air Gap Verification form and Backflow Assembly Test & Maintenance Report must be on file with each water supplier
you obtain water from and a copy kept in the vehicle.
Form must be signed and dated by a certified ABPA/ASSE backflow assembly tester. A Backflow Assembly Test & Maintenance
Report shall be submitted along with the Air Gap Verification form and kept on file. The form must be filled out and signed by the
owner /owner’s agent who is responsible for the fabrication, maintenance and repair of any air gap to be used on tank trucks, trailer
mounted fill spouts or any other tank designed to carry water obtained from any potable water distribution system. A certified
ASSE/ABPA tester can be found at
(search “Backflow” in “Denver, Co”).
Form must also be signed by the owner of the conveyance and notarized.
MINIMUM SPECIFICATIONS FOR A MOBILE AIR
GAP: (Applies to external piping only)
1. Vertical distance from discharge pipe to the flood level
of
the container must be at least two times the diameter of
the
discharge pipe.
2. No hoses to prevent spillage or splashing shall be attached
to the discharge pipe at any time.
VEHICLE:
Make: _________________________ License: ______________________ ID Number: _______________
Tank Size: ___________ Gal
. Fill Pipe Diameter: ______ Inches Air Gap Distance: _______Inches
Address of normal storage location of vehicle: __________________________________________________
COMPANY: ___________________________________________________________ PHONE: (____)__________________
ADDRESS: __________________________________________________________ STATE: _______ ZIP:______________
OWNER/PRESIDENT: ___________________________________________ TITLE: ________________________________
The above-described vehicle and air gap specification exists at this time and will be maintained at all times in the future. I understand
that not maintaining this air gap specification is in violation of Colorado Department of Health Regulations and Colorado State
Plumbing Code. Violation of these Regulations can result in all permits for obtaining water from a public water system being revoked
in addition to other fines and penalties.
Certified ABPA/ASSE Air Gap Tester: ___________________________________________________________________
Signature
Date
_______________________________
Certification Number
Owner/Owner’s Agent: __________________________________________________________________________________
Signature
Date
State of: ___________________________________________
County of: ______________________________________
On this ____________ day of _____________________, 20 ____, before me, the undersigned, a Notary Public in and for said
State personally appeared, is known to me, or proved to be on the basis of satisfactory evidence to be the person(s) who name(s)
is (are) subscribed to in the foregoing instrument and acknowledged that he/she executed the same.
Witness my hand and official seal
Signature: ____________________________________________
(reserved for official seal)
____________________________________________
My commission expires
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