CORPORATION OF THE TOWN OF GRIMSBY
Department of Public Works
Title:
Document #:
Backflow Preventer Testing & Inspection Report - RP
PW-ES-WD-FRM-018-008
Backflow Preventer Testing & Inspection Report - RP
Revision Number: 4
PW–ES-WD-FRM-018-008
Location Address:
Occupant:
Owner of Device:
Owner Contact:
Telephone
( __ __ __ ) __ __ __ -__ __ __ __
Postal Code
__ __ __ - __ __ __
Owner Address:
Name of Certified Person:
Company Name:
Certification Persons Qualifications:
□ Licenced Plumber □ Journeyman Plumber □ Apprentice Plumber
Certificate # (CCC Specialist):
□ Certificate Attached
Make of Test Kit:
Telephone
( __ __ __ ) __ __ __ -__ __ __ __
□ Fire Sprinkler Fitter □ Lawn Irrigation Installer
Certificate # (Plumber / Fire Sprinkler Fitter / Lawn Irrigation Installer):
□ Certificate Attached
Model #:
Serial #:
Calibration Due Date (mm/dd/yyyy):
__ __ / __ __ / __ __ __ __
Reduced Pressure Principle Backflow Preventer
Purpose of Device:
□ Premise (Domestic) □ Premise (Sprinkler) □ Premise (Other) □ Zone
Type of Device:
□ RP
Make of Device:
Model #:
Type of Test:
□Initial □Annual □Replacement
Test
Size:
□Inch
______ □mm
Serial #:
Test Date (mm/dd/yyyy):
Shut-off
__ __ / __ __ / __ __ __ __
Valve No. 2:
Differential Pressure
Relief Valve
□Failed to Open
□Opened at:
Location of Device:
□Leaked
□Closed Tight
Check Valve 1
Line Pressure
□ kPa
at Time of Test: ___________ □ psi
Check Valve 2
□Leaked
□Closed Tight
□Leaked
□Closed Tight
Test
Results
□ kPa
□ kPa Pressure Differential across
□ kPa □ Passed
Pressure Differential across
1st Check Valve (No Flow)
2nd Check Valve (No Flow)
______ □ psi
______ □ psi
______ □ psi
□ Failed
Device Failure, Repairs and Re-Test (If the device fails for any reason, complete this section and note repair below)
Reason for failure (if apparent):
Differential Pressure
Relief Valve
Repairs
01 □ Cleaned
Replaced
Check Valve 2
13 □ Cleaned
Replaced
22 □ Cleaned
Replaced
Shut-Off
Valve 2
31 □ Cleaned
Replaced
02 □ Disc Upper
08 □ Diaph. Sm.
14 □ Disc
20 □ Diaphragm
23 □ Disc
29 □ Diaphragm
32 □ Disc
03 □ Disc Lower
09 □ Upper
15 □ Spring
16 □ Guide
30 □ Other
(describe
33 □ Seat
10 □ Spacer
21 □ Other
(describe
24 □ Spring
04 □ Spring
05 □ Diaph. Lg.
11 □ Seat
17 □ Pin Retain
06 □ Upper
12 □ Other
(describe above)
18 □ Hinged Pin
27 □ Hinged Pin
19 □ Seat
28 □ Seat
□Leaked
□Closed Tight
□Leaked
□Closed Tight
07 □ Lower
Re-Test
Check Valve 1
□Failed to Open
□Opened at: ________ □ kPa □ psi
Re-Test Date (mm/dd/yyyy):
__ __ / __ __ / __ __ __ __
Pressure Differential
across 1st Check
Valve (No Flow)
above)
□ kPa
______ □ psi
25 □ Guide
26 □ Pin Retain
above)
34 □ Other
(describe
above)
Re-Test
Results
Pressure Differential
across 1st Check
Valve (No Flow)
□ kPa
______ □ psi
□ Passed
□ Failed
Remarks:
I certify that I have tested the above device in accordance with the Corporation of the Town of Grimsby’s By-Law No. 09-63
Signature of
Registered Tester:
Date (mm/dd/yyyy):
__ __ / __ __ / __ __ __ __
(Town of Grimsby)
Form Checked By:
Date (mm/dd/yyyy):
__ __ / __ __ / __ __ __ __
This is a Controlled Document printed on July 5, 2012. It will expire in 7 days.
Distribution:
• Town of Grimsby
• Certified Person (Plumber)
• Owner/Occupant
DO NOT PHOTOCOPY
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