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

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

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  • 50 check-boxes
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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)
CHICK FIL A 02645
18839034
2106 HIGHWAY K
Mech room
65
Rpz
Watts
009 m2
336437
7ft
2.9
7.2
4.3
Tony Witt
Marmic Fire and Safety
34-11613
5 19 20
O FALLON
MO
63368
1200
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Antifreeze loop
5 19 20
St. Louis
11694 Lackland Road
MO
click to sign
signature
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Record of Obstruction Investigation
DATE:
SYSTEM(S) INVOLVED
WORK ORDER #:
WET
CUSTOMER
DRY
ADDRESS
PRE-ACTION
DELUGE
CONTACT
OTHER
EMAIL
DATE OF PREVIOUS INTERNAL PIPE INSPECTION:
PHONE
inspector's name
LICENSE
inspector's signature
I state the information on this form is correct at the time and place
of my inspection,and that all equipment tested at this time was left
in operational condition upon completion of this inspection except
as noted.
An examination of representative section of this sprinkler system has been made to determine internal conditions
INITIAL EXAMINATION DATA:
1. Number of branch
lines examined:
2. Number of cross
mains examined:
3. Number of mains
examined:
4. Number of
gauges
replaced:
5. Alarm valve
information:
6. Other points
examined (describe):
RESULTS OF INITIAL EXAMINATION:
The interior of the sprinkler piping appears in satisfactory condition
The sprinkler systems are in need of internal cleaning. Some of the pipes
were found to be partially full of foreign materials.
(specify nature of internal stoppage)
EXAMINATION SUBSEQUENT TO CLEANING SYSTEM:
7. Number of branch
lines examined:
8. Number of cross
mains examined:
9. Cleaning method
used?
10. Other points examined (describe):
RESULTS OF EXAMINATION SUBSEQUENT TO CLEANING SYSTEM:
The interior of the sprinkler piping appears in satisfactory condition
If interior of piping other than
satisfactory, describe:
Owner / designated rep name
DATE
Owner / deisgnated rep signature
I state that the information on this form has been explained at my
request and a copy provided to me regarding this inspection,and
that all equipment tested at this time was left in operational
condition upon completion of this inspection except as noted.
page 1 of 2
888-462-7642
18839034
CHICK FIL A 02645
2106 HIGHWAY K
O FALLON
10
5
2
1
MO
✔
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A Witt
05/19/2020
11694 Lackland Road
St. Louis
MO
Record of Obstruction Investigation and Internal Condition of Fire Protection System Piping
Annual Ice Obstruction on Internal
Investigation applicable? 5 Year Investigation and Prevention
1. System in service before
conducting investigation?
9. System in service before conducting
investigation?
2. Pertinent parties notified before
conducting investigation?
10. Pertinent parties notified before
conducting investigation?
3. System impairment program
implemented before conducting
investigation?
11. Adequate drainage ensured before
draining system?
4. Piping internally inspected for ice
obstruction at entrance points to
refrigerated areas?
12. System impairment program
implemented before conducting
investigation?
5. Alternative non-destructive
examination method utilized?
13. Flushing connection of one main
and sprinkler of one branch line
removed?
6. No ice obstruction found?
14. Alternative non-destructive
examination method utilized?
7. Additional piping exmained to
ensure no ice blockage exists if "NO"
on item #6 above?
15. No foreign material indicated by
non-destructive examination method?
8. Pertinent parties notified of
investigation conclusion?
16. Interior of main, branch line, and
sprinkler outlet checked for presence
of tubercules or slime?
COMMENTS:
17. No tubercules or slime observed?
18. Complete flushing program
implemented where observed material
sufficient to obstruct sprinklers?
Description:
Date:
Testing for Microbiologically influenced corrosion (MIC)
19. Tubercules or slime (if present)
tested for indications of MIC?
Description:
Date:
20. Material test results do not indicate
presence of MIC?
Desciption:
Date:
21. MIC abatement / monitoring
program implemented, if "NO" on item
#20 above?
Description:
Date:
22. Pertinent parties notified of
investigation conclusion?
23. ALARM PANEL CLEAR?
24. SYSTEM RETURNED TO
SERVICE?
page 2 of 2
YES
NO
N/A
YES N/A
NO
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05/2020
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BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

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Completed 15 June 2021

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