Backflow prevention federal and state regulations require public potable water supplies to adopt rules to prevent contamination in their water systems. Lws manually reads the reports before we enter them. A copy of a completed backflow prevention device test report must be submitted to the utilities department to verify compliance. Failure to return this test report on time may result in further action, up to and including, termination of water service.
Tampering with id plate will result in you being required to replace backflow device. Waterworks design branch 320 507 west broadway, vancouver, bc v5z 0b4. This sample report includes several optional fields that commonly appear on other test reports. Learn more about business development, emergency services, legislation, mayors court, city council, zoning and more.
Never have to add your personal info to a backflow form. Add your personal information once and save it to the form. I certify that this report is accurate, and i have used wac 246290490 approved test methods and test. City of gahanna, located in central ohio, offers family events, great parks and communities, plus the activities and businesses found at creekside. Backflow prevention assembly test and maintenance report i l l e g i b l e o r i n c o m p l e t e r e p o r t. At the time of test, the above assembly performed as reported and was placed back into service after the test. Gwinnett county department of water resources backflow.
To comply with these mandates, the san marcos city council has adopted an ordinance, the cross connection control and backflow prevention program. Prior to testing any part of the fire protection system, you must notify the fairfax county. Sample backflow preventer inspection and field test report. I have completed the above test and hereby certify that this backflow device performed satisfactorily and meets all federal, state, and local. Software designed for the backflow tester by the backflow tester for the cheapest price. City of novi, michigan backflow preventer test report. This report should help backflow assembly testers bats and water systems comply with the minimum test. At the time the test is conducted by the certified tester, he or she will complete a backflow prevention assembly test report form, provide you with a copy, and either you or he must send chesterfield county a copy of the form for the countys records. Reduced pressure principle assembly double check valve assembly. Backflow prevention devices protect plumbing systems and our public water supply by preventing backflow.
This means you can save it to your computer and then email it to the customer, the utility and yourself. Store pnwsawwa manuals, test result forms, donations. Backflow device test report metropolitan utilities district. To comply with these mandates, the san marcos city council has adopted an ordinance, the cross connection control and backflow prevention program, to protect the citys potable water supply from contaminants backflowing from a customers water system. Test report books effective april 18, 2016, backflow testers will be required to purchase test report books that are printed in triplicate original, pink and yellow copies. Cross connections city of norfolk, virginia official. Failed, illegible or incomplete reports will not be accepted. Backflow maintenance and test report pdf backflow resident irrigation questions pdf cross connection control pdf permitted termination of system form pdf plumber and tester list pdf public works backflow revised ordinance pdf. Weve developed a sample test report to complement the rule.
The fillable test form can be downloaded from the hcwa website. Backflow device test report service address name of premises location of device device manufacturer model size serial number. Backflow prevention assembly test report pdf backflow prevention guides. This form is to be completed for each test of each. This is a 16 hour class designed to certify the attendee in backflow. I hereby certify that the above backflow prevention device has been in constant use at this location during the entire prescribed interval between test periods and during that period this. Backflow test form pdf fill online, printable, fillable, blank. Federal and state regulations require public potable water supplies to adopt rules to prevent contamination in their water systems. Government city services public works cross connection control backflow preventer test report. The purpose of the cross connection program is to protect the city of arlington water supply system by eliminating potential sources of contamination resulting from illegal cross connections and backflow. The purpose of these rules is to provide for the certification of individuals who conduct crossconnection control surveys and inspect test backflow. Backflow is the reversal of the normal flow of water.
Backflow prevention assembly test report page 1 of 1 this publication can be made available in alternate formats braille, large print, computer diskette, or audiotape upon request. A complete report includes all identifying information for backflow device and plumber tester technician. Backflow device test report service address name of premises location of device device manufacturer model size serial number test kit manufacturer serial number date certified rp new installation dc dcda rpda line pressure reduced pressure principle assembly. Domestic, irrigation, fire, boiler, carbonator, swimming pool, cooling tower, water cooled ice maker or other. Its caused by pressure differences and can allow contaminants from an irrigation system, boiler, or other source to enter a home or buildings plumbing system or the public water supply. The purpose of these rules is to provide for the certification of individuals who conduct crossconnection control surveys and inspect test backflow prevention devices.
Meter numbers andor other pertinent information must be submitted. Test mark one mark one opened at mark one mark one before leaked leaked lbs. Return completed backflow assembly test reports within 30 days of test. Backflow prevention assembly test and maintenance report i l l e g i b l e o r i n c o m p l e t e r e p o r t s w i l l n o t b e a c c e p t e d. This report should help backflow assembly testers bats and water systems comply with the minimum test report content requirements in the operator certification rule. Test kit manufacturer serial number date certified. Service address name of premises location of device device manufacturer model size serial number. Rp dc dcda rpda reduced pressure principle assembly. Residential irrigation backflow guide pdf commercial irrigation backflow guide pdf videos. Domestic fire irrigation a static pressure drop across check valve no. Forms being developed 2 we are improving the experience daily. Submit the backflow prevention device test report form pdf. The information in this report is true, complete, and accurate. Texas commission on environmental quality form tceq.
I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the state of nebraska health and human services, department of regulation and licensure, title 179, and the metropolitan utilities district, and that all reading are true and accurate to the best of my knowledge. The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is c ertified to be operating within acceptable parameters. This sample report includes several optional fields that commonly appear on other test reports used in washington. Test gauge information i have completed the above test and hereby certify that this backflow device. New jersey department of environmental protection quarterly. Backflow prevention device test report pdf certified local testing companies pdf how to protect your plumbing system pdf class information. I certify that this report is accurate, and i have used wac 246290490 approved test methods and test equipment. The form can be printed and completed by hand, or 2. This page includes newwas rules governing crossconnection and control certification, including changes being implemented as of january 1, 2017. Backflow prevention devices are required to be inspected and tested annually by a certified backflow prevention device tester. Backflow prevention assembly test report epcor water services closed tight leaked leaked replaced. The waterworks operator certification rule effective january 4, 2014 includes a section on backflow preventer inspection and field test report content wac 246292036. Service address name of premises location of device device. The readings need to fall within the test procedures guidelines.
Contact planning and development at 602 2627811 voice or 602 5345500 tty. Backflow preventer backflow prevention is important the purpose of the cross connection program is to protect the city of arlington water supply system by eliminating potential sources of contamination resulting from illegal cross connections and backflow. Type of use protection orientation denver water pvb air inlet rp buffer retest results tightness differential. This instructor guide has been compiled to aid asse approved instructors in conducting tester certification and recertification classes in accordance with the asseiapmoansi series 5000, cross. Texas commission on environmental quality form tceq20700. Water resources commissioner annual report pdf drive, ride, walk novi road and nonmotorized facility construction cross connection control. All testing must be done by a state certified backflow prevention. Backflow prevention assembly test report city of bellevue water quality box 90012 bellevue, wa 98009 emailto. Backflow assembly test report send completed report to.
I personally inspected and fieldtested the backflow assembly using field test procedures meeting wac 246290490 and test equipment meeting wac 246292034. Backflow prevention device and annual testing seabrook. The above report is certified to be true at the time of the test. Page 1 of 3 112020 backflow assembly test report cross connections department fairfax county land development services 12055 government center parkway, suite 307, fairfax, va 22035.
Leaked leaked repairs closed tight closed tight differential closed closed pressure tight tight diff press diff press repairs and new materials. At the time the test is conducted by the certified tester, he or she will complete a backflow prevention assembly test report form, provide you with a copy, and either you or he must send. Backflow assembly test report henrico county, virginia. If you have any questions or comments call 75189660 notice. Backflow prevention provides protection of the drinking water system from contaminants and pollutants that can come from cross connections and changes in the hydraulic conditions within the system.
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