HomeMy WebLinkAboutBlank Test Report FormIOWA CITY – PUBLIC DRINKING WATER PROGRAM
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
FILE NUMBER
CUSTOMER ADDRESS
SITE ADDRESS
DEVICE LOCATION
DATE OF TEST TIME A.M.
P.M.
SUPPLY PRESSURE
LBS.
AIR GAP (2 x SUPPLY DIAM.) N/A PASS
SUPPLY_______________ IN. GAP ____________ IN. FAIL
TYPE OF ASSEMBLY
MANUFACTURER MODEL
SIZE SERIAL NUMBER
HEIGHT OFF FLOOR
_________________________________ (IN./FT.)
PROTECTION FROM:
FREEZING YES NO FLOODING YES NO
NEW INSTALLATION
YES NO
GAUGE CALIBRATION DATE
TESTS STEP COMPONENT TEST REQUIREMENT INITIAL TEST FINAL TEST
1: Check Valve 1 Confirmed Pressure Drop 5.0 PSID min
2: Relief Valve Opening Pressure 2.0 PSID min
3: Check Valve 2 Differential Pressure in direction of flow 1.0 PSID min
4: Check Valve 2 Held against Backpressure Yes/No
REDUCED
PRESSURE
ASSEMBLY
5: Difference (Check Valve 1 – Relief) 3.0 PSID min
1: Check Valve 1 Differential Pressure in direction of flow 1.0 PSID min
2: Check Valve 1 Held against Backpressure (optional) Yes/No
3: Check Valve 2 Differential Pressure in direction of flow 1.0 PSID min
DOUBLE
CHECK
VALVE
ASSEMBLY
4: Check Valve 2 Held against Backpressure (optional) Yes/No
1; Air Inlet Valve Opening Differential 1.0 PSID min PRESSURE
VACUUM BREAKER 2: Check Valve Closes tight in direction of flow 1.0 PSID min
1: Check Valve Differential Pressure Across Check 1.0 PSID min
2: Air Inlet Air Inlet Start to Open at 1.0 PSID min
ANTI-SPILL
VACUUM
BREAKER
3: Air Inlet Air Inlet Fully Open when supply is at atmospheric pressure Yes/No
COMMENTS:
REPAIR HISTORY
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE.
Tester’s Certification
OWNER OR REPRESENTATIVE (SIGNATURE) DATE
TEST BY (PRINT NAME)
SIGNATURE TESTER # DATE
9/02 - hisblg\drinkwtrfrm.doc