Backflow Inspections Report

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BACKFLOW INSPECTIONS REPORT
BACKFLOW TESTER’S NAME/COMPANY:
STREET ADDRESS:
******************************************************************************************************************************
CUSTOMER NAME:
MAILING CONTACT NAME AND ADDRESS:
STREET ADDRESS OF ASSEMBLY:
PHYSICAL LOCATION OF ASSEMBLY:
TYPE OF ASSEMBLY:
RP
DC
PVB
SIZE
DOMESTIC
FIRE
LAWN IRRIGATION
NEW TEST
RECERTIFICATION TEST
SPLIT SERVICE DOM/IRR
MANUFACTURER:
MODEL:
SERIAL NO:
RELIEF VALVE
CHECK VALVE #1
CHECK VALVE #2
PRESSURE VACUUM
BREAKER
OPENED AT
AIR INLET OPENED AT
LEAKED
LEAKED
__ . __ PSID
__ . __ PSID
CLOSED TIGHT
CLOSED TIGHT
DID NOT OPEN
DID NOT OPEN
DIFF. PRESSURE
DIFF. PRESSURE
__ . __ BUFFER
CHECKVALVE LEAKED
ACROSS CHECKVALVE
ACROSS CHECKVALVE
__ . __ PSID
__ . __ PSID
CHECKVALVE
HELD AT
__ . __ PSID
CLEANED ONLY
CLEANED ONLY
CLEANED ONLY
CLEANED ONLY
REPLACED:RUBBER KIT
REPLACED:RUBBER KIT
REPLACED:RUBBER KIT
REPLACED:RUBBER KIT
RV ASSEMBLY
RV ASSEMBLY
RV ASSEMBLY
RV ASSEMBLY
CLOSED TIGHT
CLOSED TIGHT
AIR INLET OPENED AT
OPENED AT __ . __ PSID
DIFF. PRESSURE
DIFF. PRESSURE
__ . __ PSID
ACROSS CHECKVALVE
ACROSS CHECKVALVE
CHECKVALVE
__ . __ PSID
__ . __ PSID
HELD AT
__ . __ PSID
INITIAL TEST: SHUT OFF VALVE #1
FINAL TEST: SHUT OFF VALVE #2
LEAKED
CLOSED TIGHT
LEAKED
CLOSED TIGHT
.
NOTE: ALL REPAIRS MUST BE COMPLETED WITHIN TWENTY ONE DAYS NON-HEALTH HAZARD / FOURTEEN DAYS HEALTH HAZARD
REMARKS AND OLD ASSEMBLY INFORMATION IF REPLACE:
I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE ASSEMBLY.
INITIAL TEST BY:
CERTIFIED TESTER NO.:
DATE:
TIME OF DAY
AM
PM
REPAIRED BY:
DATE:
FINAL TEST BY:
CERTIFIED TESTER NO.:
DATE:
TIME OF DAY
AM
PM
WATER METER NUMBER:
PLUMBING PERMIT NUMBER:
TEST KIT: DIFFERENTIAL
ELECTRONIC
LINE PRESSURE
PSI
TIME OF DAY:
AM
PM
SIGNATURE OF TESTER: ________________________________________________
RETURN TO:
Martin Ball
CROSS CONNECTION CONTROL PROGRAM
PHONE # (252) 296-3403
City of Wilson
FAX #
(252) 296-3402
P.O. Box 10
Wilson, North Carolina 27893

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