Form 2053 PDF Details

In an increasingly interconnected world, safeguarding our water supply against contamination is paramount. The Backflow Prevention Assembly Test Report plays a critical role in this essence, committed to ensuring the integrity and safety of drinking water in various settings, be it commercial or residential. Located at the crossroads of regulatory compliance and environmental stewardship, this comprehensive document outlines the necessary checks and balances. It serves not only as a record of inspection but also as a testament to a property's adherence to stringent guidelines set forth by municipal bylaws, specifically, the City of Burnaby's plumbing regulations. Items detailed within the form include essential information such as the name of the property, contact details, and specifics regarding the backflow prevention assembly—manufacturer details, model, and serial number, along with the type of assembly and its condition, whether new or a replacement. Test results decipher whether the device holds tight against pressure changes or if it leaks, necessitating repairs. The underlying purpose of this form extends far beyond a mere bureaucratic requirement. It encapsulates a commitment to public health, ensuring that preventative measures are in place and functioning correctly to protect water from pollution and contamination hazards.

QuestionAnswer
Form NameForm 2053
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesRP, Turberculation, burnaby backflow forms, blank backflow test forms

Form Preview Example

Backlow Prevention Assembly Test Report

CROSS CONNECTION CONTROL

4949 Canada Way, Burnaby BC V5G 1M2

Tel: 604-294-7542

Fax: 604-570-3608

email: crossconnectioncontrol@burnaby.ca

website: www.burnaby.ca

Name of Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commercial

 

Residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel

 

 

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location of Assembly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equipment or Zone Isolated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assembly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer (Make)

 

 

 

 

 

 

 

 

Model

 

 

 

 

 

 

 

 

 

 

Serial No.

 

 

 

 

 

 

 

 

 

 

 

 

Size

New Installation

 

 

 

 

 

 

 

 

Permit No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Existing

 

 

 

 

 

 

 

 

Replacement

 

 

 

 

 

 

 

Serial number of replaced assembly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Line pressure at time of test

 

 

 

 

 

 

 

 

 

 

p.s.i.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Assembly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RPBA

 

 

DCVA

 

 

 

PVB

 

 

RPDA

 

 

 

 

 

DCDA

 

 

 

 

AG

 

 

 

 

 

 

 

Testing Equip:

DIFF

 

 

 

DUP

 

ST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reduced Pressure Assemblies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pressure Vacuum Breaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Double Check Assemblies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Air Intake

 

 

 

 

 

 

Check Valve

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Check (A)

 

 

 

 

2nd Check

 

 

Relief Valve (B)

 

 

 

Buffer (a-b=c) (C)

 

 

Opened at

 

 

 

 

 

 

Pressure Drop

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test

DC closed tight

 

 

 

 

Closed tight

 

 

Opened at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did not open

 

 

 

 

 

 

Leaked

RP actual pres drop

 

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

 

 

 

 

 

 

 

psid

 

 

 

 

No

 

 

 

 

 

 

 

 

Passed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confirmation test Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leaked

 

 

 

 

 

 

 

 

 

 

 

 

Leaked

 

 

 

 

 

 

 

 

Failed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Repair

DC closed tight

 

 

 

 

Closed tight

 

 

Opened at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Opened at

 

 

 

 

 

 

Pressure Drop

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After

RP actual pres drop

 

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

 

psid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test

Confirmation test Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Air Gap Inspection: Required minimum air gap separation provided

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

** IF ASSEMBLY FAILS INITIAL TEST, COMPLETE REVERSE SIDE OF WHITE COPY **

 

 

 

 

 

 

 

 

 

 

Initial Test Performed by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cert. No.

 

 

 

 

 

 

 

 

 

 

 

 

Date (YMD)

 

 

 

 

 

 

 

Business Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal Code

 

 

 

 

 

 

 

 

 

 

Business Phone

I CERTIFY THAT I HAVE TESTED THE ABOVE ASSEMBLY AND THAT IT MEETS THE PERFORMANCE REQUIREMENTS OUTLINED IN THE

CITY OF BURNABY PLUMBING BYLAW

Tester’s Signature

Owner’s Representative - Please print name and sign

TEST REPORT MUST BE SUBMITTED NO LATERTHAN 10 DAYS FOLLOWING TESTING

Form 2053 Rev. Feb. 2013

Check Causes for Backlow Preventor Failing Initial Test

 

Description

 

 

NO. 1 CHECK

NO. 2 CHECK

Relief Valve

 

 

 

 

Valve

Valve

 

1.

Isolating Gate Valve(s) Passing Water

 

 

 

2.

Foreign Matter Introduced During Construction

 

 

 

 

 

 

 

 

3.

Sand or Grit Inherent to the Supply System

 

 

 

 

 

 

 

 

 

4.

Copper Filings Solder or Pipe Dope

 

 

 

 

 

 

 

 

 

5.

Nuts, Bolts, Washers, etc. (not from assembly)

 

 

 

 

 

 

 

 

 

6.

Paper, Cardboard or Sawdust

 

 

 

 

 

 

 

 

 

 

7.

Improper Assembly Installed

 

N/A

N/A

 

 

 

 

 

 

 

8.

Kinking of External Sensing Line

 

 

 

 

9.

Air Entrapment

 

 

 

 

 

 

 

 

 

 

 

 

10.

Turberculation or Rust

 

 

 

 

 

 

 

 

 

 

 

 

11.

Frozen Assembly

 

 

 

 

 

 

 

 

 

 

12.

Abnormal Rubber Disc Wear or Cuts

 

 

 

 

 

 

 

 

 

 

13.

Spring(s)

 

 

 

 

 

 

 

 

 

 

 

 

14.

O Ring(s)

 

 

 

 

 

 

 

 

 

 

 

 

15.

Loss of Interior Coating

 

 

 

 

 

 

 

 

 

 

 

16.

Disc Retainer (Fractured or Worn)

 

 

 

 

 

 

 

 

 

 

 

17.

Retain Nut

 

 

 

 

 

 

 

 

 

 

18.

Improper Casting or Machining of Assembly

 

 

 

 

 

 

 

 

 

 

19.

Guide Mechanism

 

 

 

 

 

 

 

 

 

 

 

 

20.

Obstructed Sensing Line

 

 

N/A

N/A

 

 

 

 

 

 

 

 

21.

Diaphragm Failure

 

 

N/A

N/A

 

 

 

 

 

 

 

 

22.

Replace Rubber Parts

 

 

 

 

 

 

 

 

 

 

23.

Test Cock(s) Missing from Assembly

 

 

N/A

 

 

 

 

 

24.

Improper (Unapproved) Installation

 

 

 

 

 

 

 

 

 

25.

Assembly no Longer Required

 

 

 

 

 

 

 

 

 

 

 

26.

Assembly Replaced

 

 

 

 

 

 

 

 

 

 

 

27.

Couldn’t Test (Explain below)

 

 

 

 

 

 

 

 

 

 

 

28.

Vertical Installation

Yes

No

N/A

N/A

N/A

 

 

 

 

 

29.

Other (specify) ______________________________________________________________________________________

 

___________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________________________

 

___________________________________________________________________________________________________

 

Remarks ___________________________________________________________________________________________

 

___________________________________________________________________________________________________

 

_____________________________________________________________________________________________________________________________

 

_____________________________________________________________________________________________________________________________

 

___________________________________________________________________________________________________

 

 

 

 

 

 

 

How to Edit Form 2053 Online for Free

Once you open the online PDF tool by FormsPal, you can easily complete or modify PVB here. FormsPal team is devoted to giving you the perfect experience with our tool by regularly releasing new capabilities and enhancements. Our editor is now much more useful thanks to the newest updates! Now, filling out PDF files is easier and faster than ever before. It just takes several easy steps:

Step 1: Press the "Get Form" button in the top area of this page to get into our PDF editor.

Step 2: As soon as you start the tool, there'll be the document made ready to be completed. Besides filling in various blank fields, it's also possible to do other things with the form, that is adding any text, editing the original text, inserting illustrations or photos, putting your signature on the form, and much more.

It is actually an easy task to finish the form with this detailed guide! Here is what you need to do:

1. When submitting the PVB, make certain to incorporate all of the essential blanks within its associated section. This will help to expedite the process, enabling your details to be processed efficiently and accurately.

city of burnaby backflow test report completion process described (step 1)

2. Soon after performing the last part, go on to the subsequent stage and complete the necessary particulars in these fields - First Check A, nd Check, Relief Valve B, Buffer abc C, Opened at, Pressure Drop, psid, psid, DC closed tight, Closed tight, Opened at, Did not open, Leaked, RP actual pres drop, and psid.

city of burnaby backflow test report conclusion process described (stage 2)

3. This next stage is usually straightforward - complete all of the form fields in I CERTIFY THAT I HAVE TESTED THE, CITY OF BURNABY PLUMBING BYLAW, Testers Signature Owners, TEST REPORT MUST BE SUBMITTED NO, and Form Rev Feb to complete this part.

city of burnaby backflow test report conclusion process described (portion 3)

You can easily make an error while filling out the I CERTIFY THAT I HAVE TESTED THE, thus make sure you look again before you decide to send it in.

4. Filling in No Check Valve, No Check Valve, Isolating Gate Valves Passing Water, Foreign Matter Introduced During, Sand or Grit Inherent to the, Copper Filings Solder or Pipe Dope, Nuts Bolts Washers etc not from, Paper Cardboard or Sawdust, Improper Assembly Installed, Kinking of External Sensing Line, Air Entrapment, Turberculation or Rust, Frozen Assembly, Abnormal Rubber Disc Wear or Cuts, and Springs is vital in this fourth part - ensure to invest some time and be attentive with each blank area!

city of burnaby backflow test report completion process shown (step 4)

5. While you approach the final sections of the form, you'll find a few more points to undertake. Particularly, Improper Casting or Machining of, Guide Mechanism, Obstructed Sensing Line, Diaphragm Failure, Replace Rubber Parts, Test Cocks Missing from Assembly, Improper Unapproved Installation, Assembly no Longer Required, Assembly Replaced, Couldnt Test Explain below, Vertical Installation Yes, Other specify, and Remarks must be done.

Guide Mechanism, Improper Casting or Machining of, and Test Cocks Missing from Assembly in city of burnaby backflow test report

Step 3: Prior to finishing this form, ensure that blanks were filled out the proper way. The moment you confirm that it is good, press “Done." Grab the PVB as soon as you join for a 7-day free trial. Readily access the document within your FormsPal account, along with any edits and adjustments conveniently synced! FormsPal is dedicated to the confidentiality of our users; we ensure that all information used in our tool is protected.