B08_Attachment_4_NPS_Standard_Backflow_form.pdf

This document is a maintenance and testing form for reduced pressure principle (RPP) assembly equipment used by the National Park Service at Sequoia & Kings Canyon National Park in Three Rivers, California.

The form tracks the condition and servicing of a double check valve assembly system with two check valves, a relief valve, and a PVB/SVB (air inlet) component. The initial test section documents whether equipment components held pressure, leaked, or failed to operate properly, with pressure readings recorded in PSID (pounds per square inch differential). The repairs section allows for notation of cleaning or replacement actions taken on valves. The final test section confirms whether the equipment passed or failed testing after repairs, with certification provided by a technician including date, time, and certificate number. The form includes spaces for equipment identification (manufacturer, model, size, and serial number), sub-district and location information, and comments. An acknowledgment signature line appears at the bottom of the form for completion by authorized personnel.