Backflow Prevention Device Test Form
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1Backflow Prevention Device Test Form
MUST BE COMPLETED BY QUALIFIED BACKFLOW DEVICE TESTER
TESTER INFORMATION
Tester Name
Certificate Number:
:
(If tester is different for initial test, repair or final test please check here ______and include all other tester information on back of form.)
Company:
Phone:
LOCATION INFORMATION
Service for:
Service Address:
Account Number:
Premise Number:
Meter Number:
Backflow Device Location:
TO BE COMPLETED BY TESTER
CHECK VALVE #1
CHECK VALVE #2
PRESSURE DIFFERENTIAL
PRESSURE VACUUM BREAKER
RELIEF VALVE
INITIAL TEST
Static Pressure Drop: _________
Static Pressure Drop: _________
Opened at ____________ lbs.
Air Inlet Opened at _________
Reduced pressure
Date: ______________
Check Valve Closed Tight? _________
Check Valve Closed Tight? _________
Did Not Open _________
Did Not Open _________
Time: ________ a.m. / p.m.
Check Valve Leaked? _________
Check Valve Leaked? _________
Check Valve Held At _________
Actual Pressure Drop: _________
No. 2 Shutoff Valve
Did Not Close _________
Apparent Pressure Drop: _________
Closed Tight? _________
Leaked _________
REPAIRS MADE &
MATERIALS USED
Date: ______________
Time: ________ a.m. / p.m.
FINAL TEST
Static Pressure Drop: _________
Static Pressure Drop: _________
Opened at ____________ lbs.
Air Inlet Opened at _________
Reduced pressure
Date: ______________
Check Valve Closed Tight? _________
Check Valve Closed Tight? _________
Check Valve Held At _________
Time: ________ a.m. / p.m.
Actual Pressure Drop: _________
DEVICE/TEST INFORMATION
___Commercial ___Fire Line ___Irrigation ___Other (explain):
Line pressure at time of test:
Calibration Date:
____________psi (required)
Mnf/Model No.:
Serial No.
Size:
Type
____Passed
____Failed
SIGNATURE
The above report is certified to be true at the time of the test. Signature of tester:
Date:
Please return completed form by mail or fax:
By Mail: Pennsylvania American Water, 2699 Stafford Avenue, Scranton, PA 18505
Attn. Cross Connection Department.
Fax: 570-341-3296
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