Attachment_8_Backflow_Prevention_Assembly_Test_Form_(BF-1).docx
DOCX document 59 KB Posted
- Attached to
- OLYMPIC MAYFIELD HOUSE FIRE SPRINKLER SYSTEM Federal contract opportunity
- Solicitation number
- 140P8326Q0007
About this file
This is a Backflow Prevention Assembly Test and Maintenance Record form (BF-1) used for documenting the inspection, testing, and repair of backflow prevention devices in water systems. The form is a template designed to standardize the testing and maintenance procedures for backflow prevention assemblies at specific locations.
The form captures essential information including the assembly's location, installation date, incoming line pressure, manufacturer details, model and serial numbers, and assembly type (RP, RP Detector, DC Detector, or PVB). The testing section documents initial and final test results for three critical components: differential pressure check valves (two) and relief valve, with specific measurements for pressure drops and operational status. The form includes checkboxes to indicate whether components leaked, closed tight, or opened at specified pressure settings. A repairs section allows technicians to document any corrections made between initial and final testing. The approvals section requires certification from a certified technician with company information, certificate and gauge numbers, signature, and date, followed by approval from a Regional Structural Fire Management Officer or designee. The form concludes with a pass/fail determination for the overall assembly condition and a remarks section for additional notes.
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Text version
Backflow Prevention Assembly Test And Maintenance Record (Form BF-1)
I. GENERAL INFORMATION
Address: FMSS Asset ID Number:
Location of Assembly:
Date of Installation: Incoming Line Pressure:
Manufacturer: Model No.
Serial No.: Size:
Assembly Type: |_| RP |_| RP Detector |_| DC Detector |_| PVB
II. TESTS AND REPAIRS INFORMATION
| Differential Pressure | |||
| Check Valve No. 1 | Check Valve No. 2 | Relief Valve |
| Initial Test: | |_| Leaked | |_| Leaked | |_| Opened at | psid | |||
| |_| Closed Tight | |_| Closed Tight | |_| Did not Open | |||||
| Pressure drop across the | Pressure drop across the | ||||||
| first check valve is | second check valve | ||||||
| psid | psid |
| Repairs: | List Repairs and | List Repairs and | List Repairs and | ||
| Corrections | Corrections | Corrections |
Final Test |_| Closed Tight |_| Closed Tight |_| Opened at psid
Condition of No. 1 Control Valve: |_| Closed Tight |_| Leaked
Condition of No. 2 Control Valve: |_| Closed Tight |_| Leaked
Remarks: |_| Assembly Failed |_| Assembly Passed
III. APPROVALS
Name of Technician Company Name:
Address:
Phone No.: Certificate Number: Gauge Number:
Signature of Technician:
Date:
Regional Structural Fire Management Officer (or his designee):
Date:
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