Backflow Prevention Device Repair Information & Re-Test Report Form

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BACKFLOW PREVENTION DEVICE REPAIR INFORMATION &
RE-TEST REPORT FORM
(Print Clearly)
Please Note:
Prior to repair contact the local Plumbing Dept. or Fire Dept. to find out if a permit is required for the
repair of backflow prevention device/assembly.
Backflow Preventer Failed:
RPBP
DCVA
PVB/SRPVB
______________
_____________
______”
____________
_______________________________
Make
Model
Size
Serial #
Location
For Devices Located on Domestic Line: a Massachusetts Licensed Plumber must conduct the repair of these devices.
____________________________ ________________
____/____/____
____________________
____/____/____
MA License Plumber’s Name (Print) Plumber License #
Expiration Date
Signature
Date
__________________________
________________
____/____/_____
___________________
____/____/____
Plumbing Inspector’s Name (Print) Plumber License #
Expiration Date
Signature
Date
For Devices Located on Fire Protection Line: a Massachusetts Certified Fire Sprinkler Fitter/Contractor must conduct the
repairs of these devices.
_________________________________
____________ ____/____/____
____________________
____/___/____
MA Licensed Fire Sprinkler Installer Name License #
Expiration Date
Signature
Date
Repair Date
Check Valve #1
Check Valve #2
Relief Valve
______/______/______
Cleaned only
Cleaned only
Cleaned only
Part(s) Replaced:
Part(s) Replaced:
Part(s) Replaced:
 Disc
 Spring
 Disc
 Spring
 Disc, upper
 Disc, lower
Describe Repair(s)
 Guide
 Pin Retainer
 Guide
 Pin Retainer
 Spring
 O-Rings
 Hinge Pin
 Seat
 Hinge Pin
 Seat
Diaphragm (large) upper lower
 Diaphragm  O-Rings
 Diaphragm  O-Rings
Diaphragm (small) upper lower
 Module
 Module
 Space (lower)
 Module
 Other _________________
 Other _________________
 Other ______________________
Test Kit
Make
Model
Serial #
Last Calibration
Information
________________
___________
______________
_____/_____/_____
RPBP
PVB/SRPVB
Test After
DCVA
Relief Valve
Repair
st
nd
1
Check
2
Check
Air Inlet
Check Valve
Closed Tight
Closed Tight
Re-test Date
Open at _______
______ psid
Open at ____
psid
psid
Held at ______ psid
Held at ______ psid
______/______/______
Leaked
Did not open
Leaked
Leaked
nd
2
Shutoff Valve
Closed Tight
Leaked
Re-test Result
*
PASS
FAIL
I hereby certified that I have personally tested the above backflow prevention device/assembly in accordance with
the method and procedure that I was trained, and the test result is true and shows that the device/assembly is in
proper operating condition. (Signatures required)
Backflow Device Test Conducted by a MassDEP Backflow Prevention Device Tester
___________________________ ______________
_____/____/____
________________________
(_____)______-__________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by the Facility Owner/Representative
_______________________________
___________________________
___________________________
_____/_____/_____
Facility Owner/Representative Name (Print)
Title
Signature
*
If repaired backflow prevention device fails the re-test, it must be repaired and re-test and a Backflow Prevention
Device Repair Information & Re-test Report Form must be filling out.
P://OPS/Xconn/Repair & Re-test Form rev. 07/05/2012

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