2026 Appendic D Backflow List and Test Form.pdf
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- 1798
About this file
This document is a Hanscom Backflow Prevention Device List and Inspection/Maintenance Report Form for Hanscom Air Force Base in Massachusetts.
The backflow list inventory identifies 84 backflow prevention devices installed across multiple facilities at Hanscom AFB, including various mechanical rooms, fire mains, fire systems, and auxiliary locations. Devices are catalogued by facility number, location, bypass status, manufacturer (primarily AMES, WATTS, FEBCO, WILKINS ZURN, and CONBRACO), pipe size (ranging from 2" to 10"), model number, serial number, device type (DCVA, RPBP, or PVB), and valve configuration (primarily OS&Y and Butterfly valves). The inventory serves the Hanscom Public Water System and covers fire protection systems throughout the base, including satellite facilities such as Jet Aviation Hangar, LMH Fire Main, and Mass Port locations.
The accompanying inspection and maintenance report form is a Massachusetts DEP-compliant template used for documenting initial, annual, and semi-annual testing of backflow prevention devices. The form requires certified testers to record device specifications, test results for check valves and shutoff valves, relief valve performance, and air inlet valve operation. Testing must be conducted by a MassDEP-certified backflow prevention device tester and witnessed by facility representatives. Failed devices require repair by licensed Massachusetts plumbers or fire sprinkler fitters within 14 calendar days, with re-testing documented on a separate repair report form per Massachusetts Drinking Water Regulations 310 CMR 22.22(13)(b).
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Hanscom Backflow List
Facility Location By Pass Make Size Model Serial No. Type Valve
1102 Mech Room - Fire Main NO AMES 6" Colt 200 OH-1197 DCVA Butterfly 1105 Basement Fire Main NO AMES 6" Colt 200 QL-1851 DCVA Butterfly 1106 Mech Room - Fire Main NO AMES 4" 2000SS 2F02010 DCVA OS&Y
1108 Room B-9 Fire Main NO WATTS 6" 709 248309 DCVA Butterfly 1109 Basement - Fire Main NO FEBCO 6" 835-D 19617 DCVA OS&Y
1152 Mech Room - Fire System NO WATTS 6" 909 241166 RPBP OS&Y 1201 Fire Main NO AMES 6" Colt 200 LJ0318 DCVA Butterfly
1208 Inside Bldg - Fire System NO AMES 3" 2000SS 2H01365 DCVA OS&Y 1240 Fire Main, Rm 602 NO WILKINS ZURN 4" 350 AST 8570A DCVA OS&Y 1302 Fire Main A-035A NO AMES 6" Colt 200 LL0300 DCVA Butterfly
1305 Fire Main NO WILKINS ZURN 6" 350 AST 295 DCVA OS&Y 1310 ML 119 Fire System NO FEBCO 8" 825 9084 RPBP OS&Y
1312 L004 Fire System YES WATTS 3/4" 709 139230 DCVA BALL 1312 L004 Fire System YES AMES 6" 3000 0309F01 DCVA OS&Y 1322 Fire Main NO AMES 6" Colt 200 0180 DCVA Butterfly
1324 Fire Main NO AMES 6" 2000SS 44764 DCVA OS&Y 1326 Fire Main NO AMES 4" Colt 200 0089 DCVA Butterfly 1326 J-040 Fire Main NO AMES 4" Colt 200 ML0065 DCVA Butterfly 1326 137 Fire Main NO AMES 8" Colt 200 MC0478 DCVA Butterfly 1330 SL Mech Room 3 Fire System NO FEBCO 8" 805 B19109 DCVA OS&Y 1425 Fire Main NO CONBRACO 6" 6DC N00534 DCVA OS&Y 1427 Basement Fire System NO AMES 4" 2000SS 110889 DCVA OS&Y
1435 Fire Main NO AMES 6" Colt 4002 JL0638 RPBP Butterfly 1445 Mech Room - Fire Main NO AMES 6" 2000SS 149748 DCVA OS&Y
1510 Fire System NO AMES 4" 4000SS 105448 RPBP OS&Y 1511 Fire System NO AMES 4" 4000SS 5448 RPBP OS&Y
1527 Mech Room Fire Main NO WILKINS ZURN 6" 350 AST 15385 DCVA OS&Y 1531 Fire Main NO WILKINS ZURN 4" 350A U47929 DCVA OS&Y 1548 Fire Main NO AMES 6" 2000SS 50686 DCVA OS&Y 1603 Mech Room Fire Main NO WILKINS ZURN 6" 350AST 8474A DCVA
1604 Fire Main NO WILKINS ZURN 6" 350 31392 DCVA OS&Y
1607 Basement MR Fire Main NO AMES 6" 2000SS 116895 DCVA OS&Y 1608 Garage - Fire Main NO AMES 3" 2000SS DO1070 DCVA OS&Y 1610 Fire Main NO AMES 4" Colt 200 DB0364 DCVA Butterfly 1612 Fire Main NO AMES 4" Colt 200A KF0647 DCVA Butterfly
1614 Phase 1 - Fire Main NO CONBRACO 4" NV24Z W5386 DCVA OS&Y
1614 Phase 2 - Fire Main NO CONBRACO 4" 4DC NW230 DCVA OS&Y 1614 SCIF Area - Fire Main NO CONBRACO 4" 4DC NV24Z DCVA OS&Y 1618 Fire Main NO WILKINS ZURN 4" 350 AST 3336A DCVA OS&Y
1624 Fire Main NO AMES 6" Colt 200 KF2077 DCVA Butterfly 1630 Fire Main NO AMES 6" Colt 200 LK-0242 DCVA Butterfly
1642 Fire Main South Rm123 NO AMES 6" Colt 200 MB1080 DCVA Butterfly 1642 Fire Main North Rm110 NO AMES 6" Colt 200 MC0178 DCVA Butterfly 1646 Sprinkler Room NO AMES 6" Colt 200 RK-0097 DCVA Butterfly
1709A Mech Room Fire Main NO WATTS 6" 709 254553 DCVA OS&Y 1709B Mech Room Fire Main NO WATTS 6" 709 254428 DCVA OS&Y 1712 Fire Main NO AMES 4 C200 RE-1490 DCVA OS&Y 1715 Fire Room Fire System YES FEBCO 10" 826YD 9.904E+10 RPBP OS&Y
1715 Fire Room Fire System YES FEBCO 3/4" 825Y 170829 RPBP BALL 1718 Fire Main NO AMES 8" Colt 200 LL0682 DCVA Butterfly
1725 Mech Room Fire System NO FEBCO 4" 805YD 9.41E+09 DCVA OS&Y 1728 Cust Svs Closet Fire Main NO WILKINS ZURN 4" 950 A08259 DCVA OS&Y 1813 Fire Main NO WATTS 6" 774 107285 DCVA OS&Y
1827 Fire Main NO AMES 6" 2000SS 56824 DCVA OS&Y
1900 Boiler Rm Fire System NO AMES 4" 2000 20L0168 DCVA OS&Y 1993 Mech Room Fire Main NO AMES 3" 200A EJ-1677 DCVA Butterfly 1994 Boiler Room - Fire Main NO AMES 6" 2000SS 2FJ0546 DCVA OS&Y 1999 Mech Room - Fire Main NO WATTS 4" Colt 200 OE-2286 DCVA Butterfly FAA Mech Room - Fire Main NO AMES 4" 2000SS 17291 DCVA OS&Y
Jet Avia Jet Aviation Hangar - Fire Main NO FEBCO 8" 880V RPBP OS&Y
Jet Avia Hangar #17 NO AMES 4" Colt 200 QL-0634 DCVA Butterfly
LMH LMH Fire Main NO AMES 8" Maxim200 FC-0752 DCVA Butterfly Mass Port Mech Room (CAT) Fire Main NO WATTS 4" 709 181492 DCVA OS&Y
Mass Port 9A Sand Salt Barn Fire Main NO WILKINS ZURN 4" 350 J20911 DCVA OS&Y Mass Port #7 Maint Bay - Fire Sprinkler
Line NO AMES 8" Colt 200 PA1361 DCVA Butterfly
MP Trailer Fire Sprinkler - Utility Closet NO WILKINS ZURN 2" 950 XLT 4137007 DCVA Butterfly
MXRD BACKFLOW PREVENTION DEVICE Initial INSPECTION AND MAINTENANCE Annual (DCVA or PVB)
REPORT FORM Semi-annual (RPBP)
(Print Clearly)
Hanscom Public Water System Name
PWS ID #: _ _/ / /_ / / /
Facility
Hanscom Air Force Base Facility Address
Name
Hanscom AFB , MA 01731 City/Town Zip
Mailing Address
Facility Manager (See Current Listing for Phone#)
Contact Person
Cross-connection Info: ID #: _
Device Info: RPBP DCVA PVB Make Model
Supplemental protection at meter required: Yes No
Facility Owner/Responsible Party
Hanscom AFB , MA_ 01731 City/Town State Zip ( ) - ext.
Phone #
Exact location of cross-connection protected by device/ assembly
Material: Bronze Iron Stainless Steel Size Serial #
Shutoff Valve Type: Ball NRS OS&Y Butterfly Other By-pass: Yes No Auxiliary Supply
Installation: Vertically Horizontally Installation required by: State Local Are repair parts available on site? Yes No Is device installed on fire protec. system? Yes No
Test Kit Information
Make Model Serial # Last Calibration / /
RPBP PVB
DCVA Relief Valve 1st Check 2nd Check Air Inlet Check Valve
Test Date
Closed Tight Held at psid
Leaked
Closed Tight Held at psid
Open at psid
Open at
Did not open
2nd Shutoff Valve Closed Tight Leaked
Test Result PASS FAIL*
I hereby certified that I have personally tested the above backflow prevention device/assembly in accordance with the method and procedure that I was trained, and the test result is true and shows that the device/assembly is in proper operating condition. (Signatures required)
• Backflow Device Test Conducted by: (MassDEP Certified Backflow Prevention Device Tester)
Name (Print) MassDEP Cert. ID# Expiration Date Signature
• Backflow Device Test Witnessed by: (Facility Owner/Representative)
Facility Owner/Representative Name (Print) Title Signature
* If a backflow prevention device failed a test the following steps are required by the Massachusetts Drinking Water Regulations: The owner of the device must obtain the service of a Massachusetts licensed plumber or a Massachusetts licensed fire sprinkler fitter/contractor to perform the necessary repair within fourteen (14) calendar days of the failure test or from the discovery of the defect as required by the Massachusetts Drinking Water Regulations, 310 CMR 22.22(13)(b). The repaired device must be re-tested by a Massachusetts certified backflow prevention device tester.
A Backflow Prevention Device Repair Information & Re-test Report Form must be completed to report the repair(s) conducted and the re-test result. P://OPS/Xconn/Inspection & Maintenance Frm. (Revised 05/17/2010)
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