HomeMy WebLinkAboutBackflow Prevention Device test formFile Number: ______________________________________
Address: ___________________________________________
Device #______
Location: __________________________________________
Model Number:
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Serial Number:
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Device Type:
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Device Size:
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Manufacturer:
New Installation? o yes o no
Supply Pressure: lbs Air Gap (2x Supply Diam) Supply: in. Gap: in. o Pass o Fail o N/A
Height off Floor: In./Ft.Freezing Protection? o yes o no Flooding Protection? o yes o no
Gauge Calibration Date:
Comments:
Repair History:
Tests Step Component Test Requirement Initial Test Final Test
Reduced 1:Check Valve 1 Confirmed Pressure Drop 5.0 PSID min
Pressure 2:Relief Valve Opening Pressure 2.0 PSID min
Assembly 3:Check Valve 2 Differential Pressure in Direction of Flow 1.0 PSID min
4:Check Valve 2 Held Against Backpressure (optional)Yes/No
5:Difference (_____________ Check -- Relief)3.0 PSID min
Double Check 1:Check Valve 1 Differential Pressure in direction of flow 1.0 PSID min
Valve 2:Check Valve 1 Held Against Backpressure (optional)Yes/No
Assembly 3:Check Valve 2 Differential Pressure in Direction of Flow 1.0 PSID min
4:Check Valve 2 Held Against Backpressure (optional)Yes/No
Pressure 1:Air Inlet Valve Opening Differential 1.0 PSID min
Vacuum Breaker 2:Check Valve Closes Tight in Direction of Flow 1.0 PSID min
Anti-Spill 1:Check Valve Differential Pressure Across Check 1.0 PSID min
Vacuum 2:Air Inlet Air Inlet Start to Open at 1.0 PSID min
Breaker 3:Air Inlet Fully Open When Supply at Atmospheric Pressure Yes/No
Company: __________________________________
Owner: ______________________________________
Address: ____________________________________
____________________________________
____________________________________
Owner or Representative Signature: _________________________________________________________ Date:_________________________
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE.
Tested By (print name): ___________________________________________________________________ Tester #:_________________________
Tester Signature: ______________________________________________________________________________ Date:_________________________