Backflow Prevention Assembly Test Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

I. General Information

• Name:

• Mailing Address:

• Phone:

• Fax:

• Location of Assembly Address:

• Type of Building:

  Commercial

  Residential

A. Assembly Information:

• Type of Assembly:

  R.P.

  D.C.

  P.V.B.

  S.V.B.

• Date of installation:

• Incoming line pressure:

• Manufacturer:

• Model No.:

• Serial No.:

• Size:

  Select 1" 1-1/2" 2" 2-1/2" 3" 4" 6" 8"

  • 1"
  • 1-1/2"
  • 2"
  • 2-1/2"
  • 3"
  • 4"
  • 6"
  • 8"

• Location of Assembly:

• Assembly Type:

  RP

  RP detector

  DC detector

  PVB

II. Tests and Repairs Information

Gauge:

• Make:

• Serial No.:

• Date Calibrated:

  Date

• Type of Installation:

  New

  Existing

  Replacement

• Old Assembly Serial No.:

A. Check Valve #1

• Initial Test:

• Leaked

  Yes

  No

  N/A

• Closed Tight?

  Yes

  No

  N/A

• Pressure Drop Across the First Check Valve (PSI)

• List of repairs and corrections Check Valve #1:

• Cleaned only

  Yes

  No

  N/A

• Rubber Kit

  Yes

  No

  N/A

• CV Assembly

  Yes

  No

  N/A

• Disc

  Yes

  No

  N/A

• O-ring

  Yes

  No

  N/A

• Seat

  Yes

  No

  N/A

• Spring

  Yes

  No

  N/A

• Stem/Guide

  Yes

  No

  N/A

• Retainer

  Yes

  No

  N/A

• Lock Nuts

  Yes

  No

  N/A

• Other

• Gauge Pressure Across Check Valve (PSI)

• Final Test:

• Closed tight?

  Yes

  No

  N/A

B. Check Valve #2

• Initial Test:

• Leaked

  Yes

  No

  N/A

• Closed Tight?

  Yes

  No

  N/A

• Pressure drop across the second check valve (PSID).

• List of repairs and corrections Check Valve #2:

• Cleaned only

  Yes

  No

  N/A

• Rubber Kit

  Yes

  No

  N/A

• CV Assembly

  Yes

  No

  N/A

• Disc

  Yes

  No

  N/A

• O-ring

  Yes

  No

  N/A

• Seat

  Yes

  No

  N/A

• Spring

  Yes

  No

  N/A

• Stem/Guide

  Yes

  No

  N/A

• Retainer

  Yes

  No

  N/A

• Lock Nuts

  Yes

  No

  N/A

• Other

• Gauge Pressure Across Check Valve (PSI)

• Final Test:

• Closed tight?

  Yes

  No

  N/A

C. Differential Pressure Relief Valve

• Initial Test:

• Did it open?

  Yes

  No

  N/A

• If "Yes" list the PSID:

• List of repairs and corrections to Differential pressure relief valve:

• Cleaned only

  Yes

  No

  N/A

• Rubber Kit

  Yes

  No

  N/A

• CV Assembly

  Yes

  No

  N/A

• Disc

  Yes

  No

  N/A

• O-ring

  Yes

  No

  N/A

• Seat

  Yes

  No

  N/A

• Spring

  Yes

  No

  N/A

• Stem/Guide

  Yes

  No

  N/A

• Retainer

  Yes

  No

  N/A

• Lock Nuts

  Yes

  No

  N/A

• Other

• Final Test:

• Opened at (PSID):

D. Pressure Vacuum Breaker

• Initial Test:

• Did the Air Inlet open?

  Yes

  No

  N/A

• If "Yes" list the PSID:

• List of repairs and corrections to Differential pressure relief valve:

• Cleaned only

  Yes

  No

  N/A

• Rubber Kit

  Yes

  No

  N/A

• CV Assembly

  Yes

  No

  N/A

• Disc

  Yes

  No

  N/A

• O-ring

  Yes

  No

  N/A

• Seat

  Yes

  No

  N/A

• Spring

  Yes

  No

  N/A

• Stem/Guide

  Yes

  No

  N/A

• Retainer

  Yes

  No

  N/A

• Lock Nuts

  Yes

  No

  N/A

• Other

• Final Test:

• Air Inlet (PSID):

• Check Valve (PSID):

• Condition of no. 2 control valve:

  Closed tight

  Leaked

• NOTE: All repairs shall be completed within five (5) working days.

• Time:

  Date

• Buffer PSID:

• Remarks:

III. Approvals

• I HEREBY CERTIFY THAT THIS DATE IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE ASSEMBLY.

• Print Name of Tester

  Sign

• Tester's Signature

  Sign

• Testers Phone#

• Cert. No.

• Date of Inspection:

  Date

• This Assembly:

  PASSED

  FAILED