bfimform.pdf
PDF 148 KB Posted
- Solicitation number
- 36C24126Q0134
About this file
This is a Backflow Preventer Assembly Inspection and Maintenance Report Form used by Massachusetts public water systems to document cross-connection control and backflow prevention device testing. The form is designed to record initial, annual, or semi-annual testing of backflow prevention devices in compliance with Massachusetts Drinking Water Regulations 310 CMR 22.22(11).
The form collects comprehensive facility and device information, including public water system identification, facility location, facility owner details, cross-connection identification, and backflow preventer specifications (make, model, size, serial number, material, and shutoff valve type). It documents test kit information and records specific test results for different device types (RPBP, PVB, SRPVB, DCVA), including measurements for first check valve, second check valve, relief valve, air inlet, and shutoff valve performance. The form requires certification by a MassDEP-certified backflow prevention device tester and must be witnessed by a facility owner or representative. Testing procedures must comply with established methods and protocols. If a device fails testing, the form stipulates that the device owner must engage a Massachusetts-licensed plumber or fire sprinkler fitter to complete repairs within fourteen calendar days, followed by re-testing and completion of a separate Backflow Prevention Device Repair Information & Re-test Report Form to document remedial actions and re-test outcomes.
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Text version
Public Water System Name
Facility Name
_______________________________________, MA _____________
City/Town Zip
Mailing Address
Owner Name/Owner Rep. Name/Contact Person
Cross-connection Info: ID # __________________________
Backflow Preventer Info.: _________________________
Make
Supplemental protection at meter required: Yes No
PWS ID#
Facility Address
Facility Owner Name/Responsible Party
City/Town State Zip
(_________)__________-________________ ext. ________________
Phone #
Exact location of cross-connection __________________
Model Size Serial #
Material: Bronze Iron Stainless Steel
Shutoff Valve Type: Ball NRS OS&Y Butterfly Other_________________________________________
By-pass: Yes No Auxiliary Supply: Yes __________________ No
Installation: Vertically Horizontally Installation required by: State Local
Are repair parts available on site? Yes No Serv. Type: Domestic Fire Protec. Irrigation
Is the installation of this backflow preventer in compliance with the requirements of 310 CMR 22.22(11)? Yes No
Test Kit Information Make _____________ Model _______________ Serial # ___________ Last Calibration ____/____/____
RPBP
PVB SRPVB
DCVA
st
Check 2 nd
Check Relief Valve Air Inlet Check Valve
Test Date
Closed Tight
Held at ______ psid
Leaked
Closed Tight
Held at _____ psid
Open at ___ psid
Did not open
Open at ____ psid
Did not pen
Open at ____ psid nd
Shutoff
Valve Closed
Tight
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 a MassDEP Certified Backflow Prevention Device Tester
Backflow Tester Name (Print) MassDEP Cert.ID# Exp. Date Signature Phone#
Backflow Device Test Witnessed by a Facility Owner/Representative
Facility Owner/Representative Name (Print) Title Signature Date
* 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 to report the re-test result.
P://OPS/Xconn/Inspection & Maintenance Report Form #8 rev.2018-03-20
BACKFLOW PREVENTER ASSEMBLY INSPECTION AND Initial Test Initial Test MAINTENANCE REPORT FORM(Print Clearly) Annual Test (DCVA / PVB / SRPVB) Semi-annual Test (RPBP)
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