CG Academy Sprinkler Reports.pdf
PDF 7 MB Posted
- Attached to
- CG Academy fire sprinkler system service
- Solicitation number
- 70Z08425RCGA00002
About this file
This is a weekly/monthly fire pump inspection report form for the USCG Academy in New London, CT. The form documents inspections performed at multiple locations within the facility, specifically focused on fire pump systems and their components. The form includes sections for recording test results for RPBA (Reduced Pressure Backflow Assembly), DCVA (Double Check Valve Assembly), and PVBA/SVBA (Pressure Vacuum Breaker Assembly/Spill-resistant Vacuum Breaker Assembly) inspections.
The form specifies inspection parameters including line pressure, check valve differentials, and relief valve operations. It requires documentation of test dates, times, PSI readings, and pass/fail results. The inspection location shown is the Alumni Center (1st Floor Next To Men's Room) Key #6, with equipment details including a Wilkins Model 350A 6" assembly with serial number U02289. The form includes space for certified tester information, CT license numbers, and dates, with visual inspections noted for July 11, 2024. The form is designed for tracking fire protection system compliance and maintenance over time, with spots for recording up to 26 separate inspection entries.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 70Z08425RCGA000020001_US.pdf | ||
| 70Z08425RCGA00001 Questions and Answers.pdf | ||
| Attachment V - Past Performance Questionnaire.doc | DOC document | |
| Attachment II - Appendix C.pdf | ||
| Attachment IV Campus Map.jpg | JPG image | |
| Attachment I - USCGA Fire Sprinkler Schedule revised.xlsx | XLSX spreadsheet | |
| 70Z08425RCGA00002_0_US.pdf | ||
| Attachment III - Wage Determination 2015_4111_Rev28.pdf |
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Text version
203-440-0550 Office /24 Hour Emergency www.facility-compliance.com
LINE PRESSURE: PSID.
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
Check Valve: _______________________ psid
No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
INTIAL TEST RESULTS TEST AFTER REPAIR OR CLEANING
SERVICE ADDRESS:
CROSS-CONNECTION CONTROLLED:
LOCATION:
MODEL: SIZE: SERIAL NO:
Backflow Prevention Form
NAME OF FACILITY:
STATE OF CT APPROVED ASSEMBLY:
Yes No
METER READING
No. 2 Check Valve: Closed Tight Leaked
Closed Tight Leaked
DCVA
No. 1 Check Valve: Differential psid
No. 2 Check Valve: Differential psid
Passed Test: Yes No
Leaked
Leaked
Date: ______________________ Certified Tester's Signature
Repaired By:
Certified Tester's Signature
CT License No: _____________
Initial Test By: _________________________________ Cer. No: __________________
Repair Person's Printed Name
Repair Test By: Cer. No: __________________ Date: ______________________
Date: ______________________
Passed Test: Yes No
RPBA
Relief Valve Opened psid
Yes No
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
PVBA/
SVBA
CERTIFIED TESTER'S TYPED OR PRINTED NAME
AG Approved Air Gap: Yes No
PLEASE RECORD REPAIR INSPECTION CLEANING
INFORMATION IN SECTION BELOW
Is this a proper installation? FIRE SERVICE BY-PASS METER
Pipe Diameter _____ inches Seperation ________ inches
REMARKS:
Test Equipment: Make: _____________ Model: _______________ Serial #: ________ ___________Accuracy Date: ____________ I CERTIFY THIS REPORT IS ACCURATE, AND THAT I HAVE USED MANUFACTURER APPROVED TEST METHODS
CERTIFIED: _____________________________________________________________________________________________
Failed to Open
Air Inlet valve fully opened: Yes No Check Valve: _____________________________ psid
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS psid
Relief Valve Opened No. 2 Check Valve: Closed Tight
Leaked Closed Tight
Leaked
Passed Test:
Yes Yes psid
No psid psid psid
No. 1 Check Valve: Differential
No. 2 Check Valve: Differential
Passed Test: Yes No
Leaked
Leaked
Passed Test: Yes No
Leaked
Air Inlet: Opened psid
Failed to Open
Air Inlet valve fully opened: Yes No
File details come from the government source that posted it. Updated .