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)
LIVING WORD CHRISTIAN SCHOOL
21526785
1610-1614 WILLOT ROAD
Basement Sprinkler Room
Rpz
Watts
909
2"
2'
3.2
7.9
4.7
Tony Witt
Marmic Fire and Safety
34-11613
06/22/2021 09:00am CDT
SAINT PETERS
MO
63376
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
06/22/2021 09:00am CDT
St. Louis
11694 Lackland Road
MO
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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)
LIVING WORD CHRISTIAN SCHOOL
21526785
1610-1614 WILLOT ROAD
Basement Sprinkler Room
DC
Wilkins
350
4"
3'
2.4
2.6
Tony Witt
Marmic Fire and Safety
34-11613
06/22/2021 09:00am CDT
SAINT PETERS
MO
63376
✔
✔
✔
✔
✔
✔
✔
06/22/2021 09:00am CDT
St. Louis
11694 Lackland Road
MO
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BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

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Completed 29 June 2021

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