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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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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Kitchen ice machine

Rpz

Watts

909

3/4

502473

2.2

8.0

5.8

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613

05/18/2021 07:00am CDT

ST CHARLES

63301

730

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Dish machine room northward cabinet

Rpz

Watts

009

3/4

75649

2.0

6.8

4.8

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

800

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Outside bakery

Rpz

Watts

009

3/4

34744

2.2

6.2

4.0

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

815

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Dishwasher station

Rpz

Watts

009

1/2

377815

2.4

7.2

4.8

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Kitchen steak house

Rpz

Watts

009

1/2

177601

2.2

7.5

5.3

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

900

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Kitchen steak house

Rpz

Watts

009

3/4

27514

2.6

7.4

4.8

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

915

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Ice machine sh119 cove

Rpz

Watts

009

1//2

180863

2.0

6.2

4.2

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

925

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Inside service door 119

Rpz

Watts

909

3/4

502468

2.1

7.4

5.3

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Falcon kitchen

Rpz

Watts

009

1/2

A04289

2.5

7.0

4.5

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613. 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

930

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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)

AMERISTAR CASINO

21575956

ONE AMERISTAR BLVD

Falcon kitchen

Rpz

Watts

009

1/2

425255

2.0

7.4

5.4

Kevin Hergenroeder, Tony Witt

Marmic Fire and Safety

34 11613 3 24

05/18/2021 07:00am CDT

ST CHARLES

63301

940

✔

05/18/2021 07:00am CDT

St. Louis

11694 Lackland Road

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

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Completed 21 May 2021

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