Backflow Prevention Device Test Report

Facility Information

Facility Address:

Postal Code:

Business Name:

Occupant:

Phone #:

Property Owner:

Phone #:

Owner's Address:

Postal Code:

Contact Person:

Phone #:

Tester Information

Testing Company:

Phone #:

Tester's Name:

OWWA Cert. #

Test Kit:

Serial #

Test Kit Calibration Date:

Device Information

Manufacturer:

Model #:

Size:

Serial #:

Device Location:

Date of Test:

Failed/Passed

Failed

Passed

Line pressure at time of test: psi

Orientation of device:

Horizontal

Vertical

If replacing an existing device, provide serial # of original device:

Reduced Pressure Backflow Device

Check Valve No. 1

Pressure Diffential across Check Valve (psi)

Did the check valve leak or close tight.

Leaked

Closed tight

Check Valve No. 2

Pressure Diffential across Check Valve (psi)

Did the check valve leak or close tight.

Leaked

Closed tight

Relief Valve

Failed to open

Opened

Shut off valve #1

Leaked

Closed tight

Shut off valve #2

Leaked

Closed tight

Double Check Valve Assembly

Check Valve No. 1

Pressure drop across valve psi.

Did the check valve leak or close tight?

Leaked

Closed tight

Check Valve No. 2

Pressure drop across valve psi.

Did the check valve leak or close tight?

Leaked

Closed tight

Pressure Vacuum Breaker

Air inlet valve opened at psi?

Did the air inlet fail to open or close tight?

Failed to open

Closed tight

Check valve

Did the Check valve leak or close tight?

Leaked

Closed tight

Shut Off Valve No. 1

Did shut off valve #1 leak or close tight?

Leaked

Closed tight

Shut Off Valve No. 2

Did shut off Valve #2 leak or close tight?

Leaked

Closed tight

Personal information on this form will be collected, used and disclosed in a confidential manner in accordance with the Municipal Freedom of Information and Protection of Privacy Act. The information will be used for the our purpose of responding to your request for service and improving program and service delivery issues.

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Backflow Prevention Device Test Report

Facility Information

Tester Information

Device Information

Reduced Pressure Backflow Device

Check Valve No. 1

Check Valve No. 2

Double Check Valve Assembly

Check Valve No. 1

Check Valve No. 2

Pressure Vacuum Breaker