Ensuring the safety of drinking water within a community is a paramount responsibility, one that necessitates meticulous attention to the functioning of backflow prevention devices. Such devices are critical in safeguarding water systems from contamination due to backflow and back siphonage. In the City of Goose Creek, South Carolina, this responsibility is underscored by the Backflow Device Certification Form, a comprehensive document that serves as a linchpin in the Cross Connection Control Program. This form, integral to the Field Testing and Maintenance Report for Backflow Prevention Devices, mandates thorough documentation—from the certified tester’s information to specific details about the tested device, including type, size, make, model, and serial number. Moreover, it requires precise records of the tests conducted, including initial and post-repair readings, to ensure the device's effective operation. Significantly, the form is not just a mere procedural requirement; it embodies the city’s adherence to the Safe Drinking Water Act, enforced by the South Carolina Department of Health and Environmental Control, aimed at protecting water systems from potential hazards. The exigency for testers to submit this form, complete with details of any failures, repairs, or replacements, within a stipulated timeframe, along with their current test device calibration certification, underscores the stringent measures in place to maintain the sanctity of water supplies. This document not only facilitates compliance with regulatory standards but also serves as a testament to a shared commitment towards ensuring the quality and safety of drinking water for the residents of Goose Creek.
Question | Answer |
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Form Name | Backflow Preventer Inspection Form Blank |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | sc backflow device form, backflow test form, Tester, TESTERS |
Backflow Device Certification Form
Cross Connection Control Program / Field Testing and Maintenance Report Form / Backflow Prevention Devices
For City of Goose Creek, SC
Certified Tester
Customer:
Service Address:
Billing Address: (if different)
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Print Name |
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Company Name |
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Address |
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Phone Number |
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FAX |
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Type: |
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Size: |
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Make: |
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Model: |
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Serial #: |
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Application: |
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Water Meter #: |
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Account #: |
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Comments:
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Check No. 1 |
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Check No. 2 |
#1 Gate |
#2 Gate |
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or |
or Ball |
or Ball |
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Relief Valve |
(Check One) |
(Check One) |
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Test |
Mark One: |
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Mark One: |
Opened at |
Mark One: |
Mark One: |
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Before |
Leaked: |
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Leaked: |
lbs. |
Leaked: |
Leaked: |
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Repairs |
Closed |
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Closed |
Differential Pressure |
Closed |
Closed |
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Tight: |
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Tight: |
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Tight: |
Tight: |
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Diff Press |
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Diff Press |
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Repairs |
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and |
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New Materials |
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Test |
Mark One: |
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Mark One: |
Opened at |
Mark One: |
Mark One: |
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After |
Leaked: |
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Leaked: |
lbs. |
Leaked: |
Leaked: |
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Repairs |
Closed Tight: |
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Closed Tight: |
Differential Pressure |
Closed Tight: |
Closed Tight: |
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Diff Press
Diff Press
Tested By: |
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ABOVE DATA CERTIFIED TO BE CORRECT: |
Method of Testing: |
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Test Kit Used: |
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Signature of Certifier:_____________________________________ |
Date of Test: |
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Certification Number:_____________________________________ |
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Expiration Date: _________________________________________ |
The Safe Drinking Water Act monitored by SC Department of Health and Environmental Control requires that all water purveyors in the State protect the water system from potential backflow and back siphonage by the installation of backflow devices on specified water customers. This document is the certification for the backflow device installed at the above named service address pursuant to these requirements.
INFORMATION FOR TESTERS
OIf device fails the initial test, this form should indicate the failing test, the repairs made, and the passing test.
OIf device requires replacement, please contact Rodger Spencer at Goose Creek Public Works,
OThis form must be returned to Goose Creek Public Works, P. O. Drawer 1768, Goose Creek, SC 29445 within seven (7) days of testing – FAX