BACKFLOW PREVENTION ASSEMBLY FIELD TEST REPORT
SUBMIT IN TRIPLICATE
DATE OF TEST: _________________________
NAME OF PREMISE:
CONTACT PERSON:
STREET ADDRESS: ______________________________________________________________________
____
TEL #: ___________________________________________
LOCATION OF DEVICE: _______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
TYPE OF DEVICE:
RP
D.C.
PVB
OTHER_____________ SIZE: ______________
PERMIT NUMBER __________________________________
MANUFACTURER: _____________________________________________________ METER NUMBER: _____________________________________________________
MODEL NUMBER: _____________________________________________________ SERIAL NUMBER: _____________________________________________________
PRESSURE DROP ACROSS FIRST CHECK VALVE ____________________________PSI
DOUBLE CHECK
CHECK VALVE #1
INITIAL
TEST
R
E
P
A
I
R
S
FINAL
TEST
REDUCED
CHECK VALVE #2
DIFFERENTIAL PRESSURE RELIEF
VALVE
PRESSURE VACUUM BREAKER
1. LEAKED
2. CLOSED TIGHT
1. LEAKED
2. CLOSED TIGHT
OPENED AT _____________LBS
DID NOT OPEN
AIR INLET OPENED AT
__________________LBS.
DID NOT OPEN
CLEANED
REPLACED:
RUBBER PARTS KIT
C.V. ASSEMBLY
OR
DISC
O-RINGS
SEAT
SPRING
STEM/GUIDE
RETAINER
LOCK NUTS
OTHER
CLEANED
REPLACED:
RUBBER PARTS KIT
C.V. ASSEMBLY
OR
DISC
O-RINGS
SEAT
SPRING
STEM/GUIDE
RETAINER
LOCK NUTS
OTHER
CLEANED
REPLACED:
RUBBER PARTS KIT
R.V. ASSEMBLY
OR
DISC
DIAPHRAGM
SEAT
SPRING
GUIDE
O-RINGS
OTHER
CHECK VALVE LEAKED
HELD AT _____________PSID
CLOSED TIGHT
CLOSED TIGHT
OPEN AT ________________ LBS.
REDUCED PRESSURE
CLEANED
REPLACED:
C.V. ASSEMBLY
DISC AIR ASSEMBLY
DISC. C.V.
SPRING
RETAINER
GUIDE
O-RING
OTHER
SATISFACTORY
LINE PRESSURE __________________________________________
NOTE: ALL REPAIRS/REPLACEMENT SHALL BE COMPLETED WITHIN TEN (10) DAYS.
REMARKS:
_____
____________________________________________________________________________________________________________________________________________
I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OF THE UNIT.
CERTIFIED TESTING COMPANY__________________________________________ TEST EQUIPT. USED ___________________________________________________
PASSED ___________________________________________
FAILED – REPAIR NEEDED _______________________________
INITIAL TEST BY ____________________________________
CERTIFIED TESTER NO. _________________________________
REPAIRED BY ______________________________________
DATE REPAIRED _______________________________________
FINAL TEST BY _____________________________________
CERTIFIED TESTER NO. _________________________________
MO
DAY
YR.
MO
DAY
YR.
EXP.
DATE
EXP.
DATE
CERTIFIED TESTER SIGNATURE _______________________________________________________________________________
CITY OF CORAL SPRINGS, FLORIDA • DEVELOPMENT SERVICES • BUILDING DIVISION
2730 N. University Drive • Coral Springs, FL 33065 • CoralSprings.org/building
Phone 954-344-1025 • Fax 954-344-5909