Backflow Test Report (new)

• Post:

• FM Name:

• Location of Assembly:

• Gauge Info:

• Make:

• Model:

• SN:

• Date Cal:

• Type of Assembly:

• RP

• DC

• PVB

• SVB

• SERIAL NO:

• Leaked

• Closed Tight

2. RP - Relief Valve

• Differential gauge reading when RV

• Opens PSI?

• Did not open

• Backpressure Test Leaked

• Closed Tight

• Pressure Across Check Valve #1 PSID?

• Leaked

• Tight

• Check Valve #2 Differential pressure across check valve PSID?

• Passed

• Failed

• Remarks:

• PSIG?

• CV #1 Leaked

• Inlet shut-off Valve: Leaked

• Closed Tight

• PSIG?

• CV #2 Leaked

• Outlet shut-off Valve: Leaked

• Closed Tight

• Passed

• Failed

• Remarks

• Air Inlet - Did not open

• Air Inlet - Opened

• Check Valve: Leaked

• Check Valve: Held at PSI?

• Passed

• Failed

• Remarks

• Check Valve: Leaked

• Check Valve: Held at PSI?

• Air Inlet: Did not open

• Air Inlet: Open at PSI?

• Passed

• Failed

• Remarks

• I hereby certify that this date is accurate and reflests the proper operation and maintenance of the assembly.

• Tester

• CERT No.

• Date/Time:

  Date