COUNTY OF SACRAMENTO
ENVIRONMENTAL MANAGEMENT DEPARTMENT
ENVIRONMENTAL COMPLIANCE DIVISON
10590 ARMSTRONG AVENUE, SUITE A
MATHER CA 95655-4153
(916) 875-8400 i FAX (916) 854-9274
ASSEMBLY INFORMATION
TYPE:
SIZE:
MODEL:
SERIAL NO.:
EXISTING ⇛ REFERENCE NO.:
REPLACEMENT ⇛ OLD ASSEMBLY SERIAL NO.:
BACKFLOW ASSEMBLY TEST REPORT
NEW ⇛ PLUMBING PERMIT NO.:
WATER PURVEYOR:
TYPE OF SERVICE:
IF APPLICABLE, WATER METER NO.:
BUSINESS NAME:
IRRIGATION
DOMESTIC
FIRE
SITE PHONE:
CITY:
SITE ADDRESS:
FACILITY
MFG:
ZIP:
ASSEMBLY LOCATION:
(Please use dimensions and references – Lot Lines, Property Lines, Curb, and/or other permanent features/landmarks)
OWNER /
MANAGEMENT
INTERNAL
:
(Please provide location description such as name of room and/or room / unit / suite number)
HOME OR PERSONAL INFORMATION IS NOT GIVEN ON PUBLIC RECORD SEARCHES. ARE THE ADDRESS AND THE PHONE NUMBER
BUSINESS:
MAILING ADDRESS CORRECTION REQUESTED
BELOW FOR YOUR HOME OR BUSINESS? HOME:
OWNER / CONTACT NAME (ATTN):
PHONE:
MANAGEMENT NAME (C/O):
CELL PHONE:
MAILING ADDRESS:
FAX NUMBER:
CITY, STATE, & ZIP:
OTHER:
TEST RESULTS INFORMATION
DOUBLE CHECK VALVE ASSEMBLY
REDUCED PRESSURE PRINCIPLE ASSEMBLY
DIFFERENTIAL
CHECK VALVE
NO. 2
RELIEF VALVE
CHECK VALVE
NO. 1
HELD AT: _____.____
INITIAL
TEST
PSID
R
E
P
A
I
R
TEST
AFTER
REPAIR
HELD AT: ______.______
PSID
LEAKED
CLOSED TIGHT (RP)
LEAKED
1) CLEANED
REPLACED:
2) DISC
3) SPRING
4) GUIDE
5) SEAT
6) MODULE
7) OTHER
1) CLEANED
REPLACED:
2) DISC
3) SPRING
4) GUIDE
5) SEAT
6) MODULE
7) OTHER
HELD AT: _____.____
PSID
INITIAL TEST
HELD AT: ______.______
PSID
START TIME:
END TIME:
DATE:
DATE:
PASSED
FAILED
CHECK VALVE
OPENED AT: _____._____
PSID
OPENED UNDER
2.0 PSID OR
DID NOT OPEN
OPENED UNDER
1.0 PSID OR
DID NOT OPEN
1) CLEANED
2) EXERCISED
REPLACED:
3) DISC(S)
4) SPRING
5) DIAPHRAGM(S)
6) SEAT(S)
7) O-RING(S)
8) MODULE
9) OTHER
1) CLEANED
REPLACED:
2) DISC
3) DIAPHRAGM
4) FLOAT
5) OTHER
OPENED AT: _____.____
OPENED AT: _____._____
PSID
TEST AFTER REPAIR
END TIME
AIR INLET VALVE
PSID
CLOSED TIGHT (RP)
START TIME:
ASSEMBLY:
OPENED AT: _____.____
PRESSURE VACUUM BREAKER
HELD AT: _____._____
PSID
LEAKED
1) CLEANED
REPLACED:
2) DISC
3) MODULE
4) OTHER
PSID
HELD AT: _____._____
PSID
COMMENTS:
TAG NO.: ________________
If FAILED, please mail the test report to the County and notify the appropriate water purveyor within 24 hours!
PLEASE MAIL ORIGINAL TO THE COUNTY OFFICE
FREEZE BAG?
SAC. COUNTY TESTER NUMBER:
PLEASE PRINT YOUR NAME:
FREEZE CAGE?
THOMAS GUIDE MAP, PAGE – GRID: ________________
SIGNATURE:
06/21/2011 gfb W:\DATA\FORMSARCHIVE\WP\CROSS CONNECTION\BACKFLOW TEST REPORT FORM.DOC
ORIGINAL: ENV. MGMT. DEPT. YELLOW COPY: CUSTOMER
PINK COPY: TESTER