Form Cp - Backflow Assembly Test Report - Ventura County Environmental Health Division

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Ventura County Environmental Health Division • 800 South Victoria Avenue, Ventura, CA 93009-1730
Telephone: 805/654-2813 • FAX: 805/662-6779 • Internet Web Site Address:
BACKFLOW ASSEMBLY TEST REPORT
Instructions-If any of the “Required Information” shown below is missing, your form will be returned.
5. Initial test or test after repair date
1. Facility-business name, site address, city, and assembly location
6. Assembly-passed or failed
2. Owner/Management-contact name, phone, management name, mailing address, city, state, zip
7. Tester #
3. Water Purveyor
8. Print your name
4. Assembly Information-type, size, mfg, model, serial no., type of service
BUSINESS NAME: ______________________________________________________________________________ SITE PHONE: ___________________________
SITE ADDRESS: _______________________________________________________________________________________ CITY: ___________________________
ASSEMBLY LOCATION:___________________________________________________________________________________________________________________
(Please use dimensions and references – Lot Lines, Property Lines, Curb, and/or other permanent features/landmarks)
INTERNAL
: __________________________________________________________________________________________________________________________
(Please provide location description such as name of room and/or room / unit / suite number)
OWNER / CONTACT NAME (ATTN): ______________________________________________________________
PHONE: ___________________________
MANAGEMENT NAME (C/O): ____________________________________________________________________
CELL PHONE: ___________________________
MAILING ADDRESS: ___________________________________________________________________________
FAX NUMBER: ___________________________
CITY, STATE, & ZIP: ___________________________________________________________________________
OTHER: ___________________________
WATER PURVEYOR: ______________________________________________________ If applicable, water meter #: _______________
ASSEMBLY INFORMATION
TYPE: ___________________________________
SIZE: ___________________________________
MFG: ________________________________
MODEL: _______________________________________________________
SERIAL NO: ________________________________________________
EXISTING ➤ Device No: BD _____
CHECK ONLY ONE:
_____
_____
_____
_____
_____
_____
REPLACEMENT ➤ OLD ASSEMBLY SERIAL NO: ________________________________________________________________
NEW ➤ _________________________________________________________________________________________________
TYPE OF SERVICE:
DOMESTIC
IRRIGATION
FIRE
TEST RESULTS INFORMATION
DOUBLE CHECK VALVE ASSEMBLY
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
CHECK VALVE
CHECK VALVE
DIFFERENTIAL
AIR INLET VALVE
CHECK VALVE
NO. 1
NO. 2
RELIEF VALVE
OPENED AT:_____._____
OPENED AT:_____._____
HELD AT:______.______
HELD AT:______.______
HELD AT:______.______
INITIAL
PSID
PSID
PSID
PSID
PSID
OPENED UNDER
OPENED UNDER
TEST
CLOSED TIGHT (RP)
2.0 PSID OR
1.0 PSID OR
LEAKED
LEAKED
DID NOT OPEN
DID NOT OPEN
LEAKED
CLEANED
CLEANED
CLEANED
CLEANED
CLEANED
EXERCISED
REPLACED:
REPLACED:
REPLACED:
R
REPLACED:
REPLACED:
DISC
DISC
DISC
E
DISC
DISC(S)
DIAPHRAGM
SPRING
MODULE
P
SPRING
SPRING
GUIDE
FLOAT
A
OTHER
DIAPHRAGM(S)
GUIDE
SEAT(S)
OTHER)
I
SEAT
SEAT
O-RING(S)
R
MODULE
MODULE
MODULE
OTHER
OTHER
OTHER
TEST
HELD AT:______.______
HELD AT:______.______
HELD AT:______.______
OPENED AT:_____._____
AFTER
PSID
OPENED AT:_____._____
PSID
PSID
PSID
CLOSED TIGHT (RP)
REPAIR
PSID
INITIAL TEST
DATE: _________________________
NAME:________________________________________________
PASSED
FAILED
TESTER #: PI _________________________
SIGNATURE:________________________________________________
TEST AFTER REPAIR
DATE: _________________________
NAME:________________________________________________
PASSED
FAILED
TESTER #: PI _________________________
SIGNATURE:________________________________________________
COMMENTS: _____________________________________________________________________________________________________
________________________________________________________________________________________________________________
CP 4/09

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