Backflow Preventer Inspection Form Blank PDF Details

Backflow preventers are an important part of any plumbing system, and it's important to make sure they're functioning properly. This blank form can help you ensure your backflow preventer is in good condition. The form includes all the information you need to accurately inspect your backflow preventer, so use it every time you check yours to be sure everything is running smoothly. Having a backflow preventer that isn't working properly can lead to all sorts of problems, so don't take any chances - use this form to inspect yours today!

QuestionAnswer
Form NameBackflow Preventer Inspection Form Blank
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessc backflow device form, backflow test form, Tester, TESTERS

Form Preview Example

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)

 

Print Name

 

Company Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

Phone Number

 

FAX

 

 

 

 

 

 

 

 

 

Type:

 

 

 

 

Size:

 

 

 

 

Make:

 

 

 

 

Model:

 

 

 

 

Serial #:

 

 

 

 

Application:

 

 

 

 

 

 

 

 

Water Meter #:

 

 

 

 

Account #:

 

 

 

 

 

 

 

 

 

Comments:

 

 

Check No. 1

 

Check No. 2

Air-Inlet Valve

#1 Gate

#2 Gate

 

 

 

 

 

or

or Ball

or Ball

 

 

 

 

 

Relief Valve

(Check One)

(Check One)

 

 

 

 

 

 

 

 

 

Test

Mark One:

 

Mark One:

Opened at

Mark One:

Mark One:

 

 

 

 

 

 

 

 

Before

Leaked:

 

Leaked:

lbs.

Leaked:

Leaked:

 

 

 

 

 

 

 

 

Repairs

Closed

 

Closed

Differential Pressure

Closed

Closed

 

Tight:

 

Tight:

 

Tight:

Tight:

 

 

 

 

 

 

Diff Press

 

Diff Press

 

 

 

 

Repairs

 

 

 

 

 

 

 

and

 

 

 

 

 

 

 

New Materials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test

Mark One:

 

Mark One:

Opened at

Mark One:

Mark One:

 

 

 

 

 

 

 

 

After

Leaked:

 

Leaked:

lbs.

Leaked:

Leaked:

 

 

 

 

 

 

 

 

Repairs

Closed Tight:

 

Closed Tight:

Differential Pressure

Closed Tight:

Closed Tight:

 

 

 

 

 

 

 

Diff Press

Diff Press

Tested By:

 

ABOVE DATA CERTIFIED TO BE CORRECT:

Method of Testing:

 

 

Test Kit Used:

 

Signature of Certifier:_____________________________________

Date of Test:

 

Certification Number:_____________________________________

 

 

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, 824-2200, extension 4261, to ensure new device will meet all current standards set by SCDHEC and The City of Goose Creek.

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 863-5218. Testers should submit a current test device calibration certification to the City.

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