Attachment_4__BP_-_Backflow_Device_Test_Form.pdf
PDF 119 KB Posted
- Attached to
- AKRO STRCUTURAL FIRE SUPPRESSION & CONTROL EQUIP I Federal contract opportunity
- Solicitation number
- 140P9726Q0017
About this file
This is a National Park Service (NPS) Inspection and Test Report form for backflow prevention devices, revised as of December 17, 2025. The form is completed separately for each backflow preventer system and documents inspection results for fire and life safety compliance.
The form captures comprehensive device information including park identification, location details (inside, outside, above ground, or pit), usage type (fire, domestic, or irrigation), and device specifications (manufacturer, model number, serial number, size, and orientation). The inspection covers four device types: RP (Reduced Pressure), DC (Double Check), DCDA (Double Check Detector Assembly), and RPDA (Reduced Pressure Detector Assembly). For Reduced Pressure Principal Assemblies, the form verifies relief ports are free of continuous discharge and documents date installed and date rebuilt. For Double Check Valve Assemblies, the form records initial and final pressure readings in PSID for Check Valves #1 and #2, Relief Valve, and PVB/SVB Air Inlet components, noting whether components held pressure, leaked, or closed tight. The form documents any cleaning or replacement of components and includes a Pass/Fail determination based on No. 2 Shutoff Valve closure and supply pressure readings.
The form also requires certification of forward flow testing as mandated by NPS for all backflow preventers with downstream fire sprinkler systems, including design flow rate versus actual flow rate in gallons per minute. A section documents deficiencies found and whether all corrections have been completed. Test kit information, certifier credentials, signature, and date are required to complete the inspection record in accordance with NFPA 25 standards.
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Text version
Backflow Preventer Device Page 1 of 2 Revised 12/17/25
National Park Service / AKRO Inspection and Test Report (complete a separate form for each system)
BACKFLOW PREVENTION DEVICE
Park Alpha Code:___________ FMSS Location No.: _______ FMSS Asset No: _________
Location Description: _________________________________________________________
Date of Test: _________________________________ Time: _____________________
Location: Inside Outside Above Ground Pit
Usage: Fire Domestic Irrigation
Type of Device: RP DC DCDA RPDA
Type of Inspection: Annual Inspection 5-year Internal Inspection
Manufacturer: ___________________________ Model No.: ______________________________
Size: ___________________________________ Serial No.: _______________________________
Orientation: Vert Up Vert Down Horizontal Height off Floor: ___________( in/ft)
REDUCED PRESSURE PRINCIPAL ASSEMBLE
*Relief ports on RPZ free of continuous discharge? Yes No
Date Installed:
DOUBLE CHECK VALVE ASSEMBLY
Apparent Pressure Drop
Across First Check
Valve________
Date Rebuilt:
Check Valve #1 Check Valve #2 Relief Valve PVB / SVB
Held at _______PSID
Leaked
Held at _______PSID
Closed Tight
Leaked
Opened at _______PSID
Did not open
AIR INLET
Opened at _______PSID
Did not open
Cleaned
Replaced
Cleaned
Replaced
Cleaned
Replaced
Cleaned
Replaced
________ PSID
Closed Tight
________ PSID Air Inlet _______PSID
Check Valve _______PSID
Leaked
________ PSID
F
IN
A L
R
E P
A
IR
S M
A D
E
IN
IT
IA
L
PASS FAIL No. 2 Shutoff Valve
Closed Tight
Supply Pressure ___________
Backflow Preventer Device Page 2 of 2 Revised 12/17/25
Test Kit Manufacturer: __________________ Model: ______________________________
Serial No.: _______________________________ Last Calibration Date: _________________
This certifies that the fire and life safety system has been inspected and tested for functional operation in ac-cordance with applicable NFPA 25, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.
Certifier Name (print): _______________________ Certifier Tester No.: _________________
Signature: ____________________________________________________________________
FORWARD FLOW TEST—Required by NPS for all backflow preventers where fire sprinkler systems are located downstream of the backflow preventer. The test shall include forward flow test of the system at the designed flow rate, including hose stream demand. For back-flow preventers sized 2 inches and less, forward flow test shall be acceptable to conduct without measuring flow, where the test outlet is a size to flow the system demand.
Forward Flow Test Performed: Yes No
Main Drain Test Performed: Yes No
Design Flow Rate: __________________ GPM Actual Flow Rate: ______________ GPM
If Flow Rate based on Main Drain Test, use Estimated in place of Actual.
For cases where neither Forward Flow nor Main Drain could be performed, or Main Drain flow does not meet intent of System Design, note this as a Deficiency below.
For these cases, note which of the options listed below may be applicable:
1) Reverse FDC check valve and flow out the FDC check valve
2) Dismantle riser and install temporary test header
3) Modification of riser for installation of permanent test header
Location: _____________________________________________________________________
Deficiency: ___________________________________________________________________
Recommended Resolution: _____________________________________________________
DEFICIENCIES FOUND? Yes No List items that were not corrected. Use this section or attach itemized sheet.
REPAIRS: All deficiencies have been corrected: N/A Yes No
DEFICIENCIES
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