Attachment 1 - VA BFP Testing Forms.pdf
PDF 171 KB Posted
- Solicitation number
- 36C24126Q0744
About this file
This is a NEWWA (New England Water Works Association) Backflow Prevention Device Assembly Test Report Form used to document the testing and certification of backflow prevention devices at residential and commercial properties.
The form captures comprehensive testing data for four primary types of backflow prevention devices: Reduced Pressure Backflow Prevention Device Assembly (RPZ), Double Check Valve Device Assembly (DCVA), Pressure Vacuum Breaker (PVB), and Spill Resistant Vacuum Breaker (SRVB). The form records property owner information, device specifications (make, model, serial number, size), tester certification number, and test kit calibration details. Testing parameters vary by device type and include check valve tightness evaluations, flow conditions, relief valve differential pressure (DP) opening points, and backpressure test measurements recorded in PSID (pounds per square inch differential). The form documents the test classification—whether conducted after installation, after repairs, annually, or semi-annually—and captures the downstream shut-off valve condition, line pressure in PSI, and protection type (service line at meter or fire service line). The testing results conclude with a PASS, FAIL, or OTHER designation, signed by the certified tester and witnessed by a water works official or owner agent. A remarks section allows documentation of any issues, and the form includes a checkbox for service restoration confirmation.
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Text version
NEWWA Backflow Prevention Device Assembly Test Report Form
Owner of Property Date________________ Time ______________
Mailing Address Tested by:
Certificate #:
(City,Town) (Zip)
Contact Person RPZ DCVA PVB SRVB
Make ____________ Model No. ____________
Device Address and Location Size Serial No. _________
_____________________________________________________________ Test After Installation
Device Identification Number _____________________________________ Test After Repairs
Annual Test
Test Kit Serial # _____________________Calibration Date_____________ Semi-Annual
Reduced Pressure Backflow Prevention Device Assembly (RPZ) Pressure Vacuum Breaker (PVB)
Spill Resistant Vacuum Breaker (SRVB)
Check Valve
No. 1
Check Valve
No. 2 Tightness
Flow
Condition
Evaluated
Relief Valve
DP Opening
Point
Check Valve
No. 2 DP
Check Valve
DP
Flow Condition
Evaluated
Closed Tight
Leaked
Closed Tight
Leaked
Flow
No-Flow
Opened at PSID
Did Not Open
PSID
Double Check Valve Device Assembly (DCVA) Air Inlet Valve DP Opening Point
Backpressure Test Check Valve No. 1
DP
Check Valve No. 2
DP
Flow Condition
Evaluated
Opened at _________.______
Did Not Open
TC#1 PSI TC#4 PSI
At the time of the test, the downstream shut-off valve was: Closed Tight Leaked Not Tested
Line Pressure ___________PSI Protection Type: Service Line @ Meter Fire Service Line
Signature of Certified Tester
PASS FAIL OTHER
Test Witnessed by:
Water Works Official
Owner Agent
Remarks
Service Restored
File details come from the government source that posted it. Updated .