Fillable BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

Fill Online, Printable, Fillable, Blank BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland) Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

On average this form takes 21 minutes to complete

The BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland) form is 1 page long and contains:

  • 4 signatures
  • 50 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
HSI WARRENTON MANOR
25044546
65 STATE HWY AA
Sprinkler room
50
RPZA
Wilkins
375
L09639
2'
2.5
7.8
5.3
Tony Witt,
Vendor - Marmic Fire and Safety
32-11613. 3/24
05/03/2022 07:30am CDT
WRIGHT CITY
MO
63390
1030
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
05/03/2022 07:30am CDT
Bridgeton
12882 Pennridge Drive
MO
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
HSI WARRENTON MANOR
25044546
65 STATE HWY AA
Mechanical room
55
RPZA
Watts
909
3"
175575
2'
2.4
8.0
5.6
Tony Witt,
Vendor - Marmic Fire and Safety
32-11613
05/03/2022 07:30am CDT
WRIGHT CITY
MO
63390
1050
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
05/03/2022 07:30am CDT
Bridgeton
12882 Pennridge Drive
MO
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document