Ensuring the safety and functionality of a water system is paramount for both public health and environmental protection. The Backflow Assembly Test Report form serves as a crucial tool in this ongoing effort. Designed to meticulously document the condition and performance of backflow prevention assemblies, the form captures a wide array of essential information. From the basic details of the water system, such as its name, file number, and the assembly's location, to more specific data including the assembly's size, model, and serial numbers, every section is vital. Moreover, the report delves into the heart of the assembly's functionality, assessing components like the differential pressure, check valves, and relief valves, recording whether they closed tightly, leaked, or failed to open as required. The report doesn't stop at identifying issues; it also records any repairs undertaken, listing replaced parts like discs, springs, and diaphragms. Beyond detailing initial findings and interventions, the form concludes with results from a final test post-repair, indicating the assembly's overall performance. This exhaustive approach ensures that water systems are maintained under rigorous standards, safeguarding against potential backflow incidents that could compromise water quality. In essence, the Backflow Assembly Test Report form is more than just a document; it's a comprehensive record that promotes transparency, accountability, and, ultimately, public safety.
Question | Answer |
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Form Name | Backflow Assembly Test Report Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | backflow test form pdf, backflow test form, backflow test forms, backflow test sheet |
Backflow Assembly Test Report
Water System Name: |
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File No.: |
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Location of Assembly: |
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Owner of Assembly: |
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Address: |
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City: |
State: |
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Zip |
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Size of Assembly: |
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Model No.: |
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Serial No.: |
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Name of Assembly Manufacturer: |
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I
N T I A L
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Differential Pressure |
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Check Valve #1 |
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Check Valve #2 |
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Relief Valve |
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R |
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PSI Across |
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Opened at |
# |
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P |
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PSI Across |
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Opened Under 2# or |
¨ |
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did not open |
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D |
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Closed Tight |
¨ |
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Closed Tight |
¨ |
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C |
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Leaked |
¨ |
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Leaked |
¨ |
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Pressure Vacuum
Breaker
AIR INLET: |
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Opened at |
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# |
Opened Under 1# or |
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did not open |
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CHECK VALVE: |
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Closed Tight |
¨ |
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Leaked |
¨ |
R E P A I R S
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Cleaned |
¨ |
Cleaned |
¨ |
Cleaned |
¨ |
Cleaned |
¨ |
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Replaced: |
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Replaced: |
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Replaced: |
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Replaced: |
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Disc |
¨ |
Disc |
¨ |
Disc |
¨ |
Air Inlet Disc |
¨ |
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Spring |
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Spring |
¨ |
Spring |
¨ |
Air Inlet Spring |
¨ |
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Guide |
¨ |
Guide |
¨ |
Diaphragm |
¨ |
Check Disc |
¨ |
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Pin Feather |
¨ |
Pin Feather |
¨ |
Seat(s) |
¨ |
Check Spring |
¨ |
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Hingepin |
¨ |
Hingepin |
¨ |
¨ |
Other (describe) |
¨ |
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Seat |
¨ |
Seat |
¨ |
Module |
¨ |
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Diaphragm |
¨ |
Diaphragm |
¨ |
Other (describe) |
¨ |
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Other (describe) |
¨ |
Other (describe) |
¨ |
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FINAL |
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PSI Across |
¨ |
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PSI Across |
¨ |
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Opened at |
# |
Satisfactory |
¨ |
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TEST |
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Closed Tight |
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Closed Tight |
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Reduced Pressure |
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Initial Test By: |
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Certification No. |
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Date: _______________ |
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Repaired By: |
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Date: _______________ |
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Final Test By: |
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Certification No. |
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Date: _______________ |
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This assembly's INITIAL TEST performance was: |
Satisfactory ¨ Unsatisfactory ¨ |
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This assembly's FINAL TEST performance was: Satisfactory ¨ Unsatisfactory ¨ |
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I certify the above test has been performed and I am aware of the final performance. |
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BY: ________________________________________________________ Assembly Owner Representative |
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Distribution: White - Assembly Owner |
· Pink - Tester · |
Canary - Water Utility |
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