Backflow Device Test - Double Check Valve

• Document No.

• Client

• Conducted on

  Date
• Location
  Address

• Prepared By:

  Leith Perry

  Sean Butler

Client Information

• Site Owner:

• Postal Address:

• Suburb:

• Postcode:

• Contact Person

• Site Occupier:

• Add location
  Address

• Site Contact

• Site Phone Number

Test Details

• Encumbrance Number:

• Test Type:

  Initial

  Annual Test

  Replacement

• Select date

  Date

• Tested By:

  Leith Perry

  Sean Butler

Valve Details

• Device Make:

• Model Number:

• Serial Number:

• Add media

  Media

• Device Location:

• Add media

  Media

• Add drawing

  Drawing

• Nature Of Water Use After Device

• Protection Type:

  Containment

  Zone

  Individual

Test

• Check Valve Number One

  Tight

  Leaked

• Differential Pressure (kpa)

• Check Valve Number Two

  Tight

  Leaked

• Differential Pressure (kpa)

• Downstream Isolation Valve

  Tight

  Leaked

• Valve Required Repair/Part Replacement:

  Yes

  No

• Device test result

  Pass

  Fail

Test Kit Details

• Test Kit Number: AC-20507

• Test Kit Certification Date Of Calibration: 27/03/2014

Contractor Details

• Contractor: Environ Plumbing
  Mail: PO Box 2693, Whyalla Norrie, S.A 5600
  Email: admin@environplumbing.com.au
  Phone: 1300 911531
  Licence: PGE 169335

• I certify that I have completed the required training & hold the required certifications to undertake Backflow Testing & Commissioning. Based upon these certifications I can declare that this device meets the performance requirements of AS2845

• Testers Name:

  Leith Perry

  Sean Butler

• Add signature

  Sign

• Licence Number

  PGE169335

• Phone Number:

• Select date

  Date