Wodonga Backflow Meter Inspection 2014

BACKFLOW PREVENTION TEST

• Backflow Meter Test No.

• Meter Serial Number

DEVICE

• The assessors believe the information contained within this assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on the condition of the device which was observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.
  

• Conducted on

  Date
• Please enter both address location and ... Coordinates
  Address

TEST RESULT

• Meter Size

  Select 20mm 25mm 32mm 40mm 50mm 80mm 100mm

  • 20mm
  • 25mm
  • 32mm
  • 40mm
  • 50mm
  • 80mm
  • 100mm

• Type of Use

  Oval

  Pre-School

  Garden

  Lawn

  Other Facility

• Test Result

  Pass

  Fail

• Fail Reason & Work Completed to Comply

• Test Result following work

  Pass

  Fail

• By signing this form the user identified as the inspecting plumber confirms they have tested the identified device and made good any defect the device may of had so that it conforms to the Australian Standard AS 3500.
  

• Plumber Name & Licence Number:

  Sign