Backflow Prevention Assembly Test Report - City Of Auburn Cross Connection Program - 2007
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1BACKFLOW PREVENTION ASSEMBLY TEST REPORT
City of Auburn Cross Connection Program
ACCOUNT #_______________
1305 C St. SW Auburn, Washington 98001-5910
PERMIT # BFL_______________
(253) 931-3064 or (253) 288-3169
OLD ASSEMBLY SERIAL NUMBER _______________
FAX (253) 288-7406
NAME OF PREMISE __________________________________________________________________ Commercial
Residential
SERVICE ADDRESS
CITY
ZIP
CUSTOMER’S NAME: _______________________________________________ PHONE (
) _____________________________
LOCATION OF ASSEMBLY
TYPE OF HAZARD ISOLATED
DCVA
RPBA
PVBA/SVBA
OTHER _______
NEW INSTALLATION
EXISTING
REPLACEMENT
LINE PRESSURE: _____________PSI
MAKE OF ASSEMBLY
MODEL
SERIAL NO.
SIZE
AIR GAP INSPECTION:
Yes
No
PROPER INSTALLATION: Yes
No
Required minimum air gap separation provided?
DCVA / RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
AIR INLET
INITIAL
CHECK VALVE NO.1 ____________
CHECK VALVE NO.2
TEST
OPENED AT _____ PSID
OPENED AT_______PSID
LEAKED
LEAKED
DID NOT OPEN
#1 CHECK _______PSID
CLOSED TIGHT
CLOSED TIGHT
CHECK VALVE
PASSED
AIR GAP OK? ________
CHK VALVE ______PSID
________________ PSID
_________________PSID
FAILED
LEAKED
VALUE FOR DCVA ONLY
CLEAN REPLACE
PART
CLEAN REPLACE
PART
CLEAN REPLACE
PART
CLEAN REPLACE
PART
NEW
_______
_______
_______
_______
PARTS
_______
_______
_______
_______
AND
_______
_______
_______
_______
REPAIRS
_______
_______
_______
_______
TEST AFTER
OPENED AT _____PSID
AIR INLET _______ PSID
LEAKED
LEAKED
REPAIRS
DID NOT OPEN
CLOSED TIGHT
CLOSED TIGHT
PASSED
#1 CHECK_______PSID
CHK VALVE ______PSID
_________________PSID
_________________PSID
FAILED
VALUE FOR DCVA ONLY
LEAKED
REMARKS: _________________________________________________________________________________________________
____________________________________________________________________________________________________________
TESTER’S SIGNATURE: ____________________________________ CERT. # B_____________DATE ___________________
I CERTIFY THE ABOVE REPORT TO BE TRUE.
TESTER’S NAME PRINTED: ________________________________ TESTER’S PHONE (
) ______________________
REPAIRED BY:__________________________________________ LIC. #___________________ DATE ___________________
I CERTIFY THE ABOVE REPORT TO BE TRUE.
FINAL TEST BY:
CERT. # B
DATE ___________________
I CERTIFY THE ABOVE REPORT TO BE TRUE.
CALIBRATION DATE ______/______/______ GAUGE SERIAL # _____________ SERVICE RESTORED YES
NO
"Test in accordance with performance criteria outlined in Backflow Prevention Assemblies Field Test
Procedure Approved for use in Washington State – July 1998"
ILLEGIBLE OR INCOMPLETE TEST REPORT FORMS WILL NOT BE ACCEPTED
REPAIRS, CLEANING OR FLUSHING MUST BE DOCUMENTED ON TEST REPORT FORM
TEST REPORT FORM MUST BE SUBMITTED WITHIN 30 DAYS OF COMPLETING THE TEST
ASSEMBLIES MUST HAVE TEST PORT PLUGS IN AREAS SUBJECT TO FLOODING
PLEASE MAIL COMPLETED TEST REPORTS TO (1305 C Street SW Auburn, WA 98001)
Updated: January 2007
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