On August 1st, my water meter reader came by to collect my reading for the month. I hadn't had my annual backflow assembly test done yet, so I requested he come back on September 1st. When he came back, I asked him how my reading looked. "You have a Class III violation," he said. In order for me to get off of the list and have my water turned back on, I needed to have a certified technician come out and do an inspection. The next day, I contacted my local plumber and scheduled an appointment for them to come out and take a look. After they did their inspection, it turns out that not only did I need a new backflow assembly (which luckily they were able to
| Question | Answer |
|---|---|
| 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 |
¨ |
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R E P A I R S
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Cleaned |
¨ |
Cleaned |
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Cleaned |
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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 |
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Disc |
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Disc |
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Air Inlet Disc |
¨ |
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Spring |
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Spring |
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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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