Fillable BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (city of san luis)

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BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (city of san luis)

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BROWSE CITY OF SAN LUIS (AZ) FORMS

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City of San Luis
BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT
Public Works Department
1090 E. Union St./P.O. Box 3750 • San Luis, AZ 85349
www.cityofsanluis.org
PLEASE USE A SEPARATE FORM FOR EACH DEVICE
FACILITY
FIRST / INITIAL TEST
ASSEMBLY ADDRESS
ANNUAL TEST
CONTACT NAME ZIP
OWNER / CONTACT
OWNER MAILING ADDRESS CITY STATE ZIP
CONTACT NAME PHONE
MANUFACTURER MODEL SIZE SERIAL #
IS THIS A NEW INSTALLATION? YES  NO    DOES THIS ASSEMBLY REPLACE ANOTHER? YES  NO
IF YES, OLD SERIAL #
ASSEMBLY LOCATION
SERVICE TYPE: DOMESTIC  IRRIGATION  FIRE PRESSURE VACUUM BREAKER
INITIAL TEST BY CERTIFIED TESTER # DATE
PASS
    
FAIL
REPAIRED BY CERTIFIED TESTER # DATE
FINAL TEST BY CERTIFIED TESTER # DATE
PASS
    
FAIL
COMMENTS ______________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
TYPE OF PROTECTION: RP  DC  PVB PRIMARY   SECONDARY
AIR INLET
OPENED AT __________________PSID
DID NOT OPEN .................
CHECK VALVE
HELD AT _____________________PSID
LEAKED ........................
BACK PRESSURE YES  NO
CLEANED ......................
REPLACED .....................
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
AIR INLET ___________________ PSID
CHECK VALVE ________________ PSID
CHECK VALVE #2
1. LEAKED .................
______________________ PSID
2. CLOSED TIGHT ...........
CLEANED ...................
REPLACED ..................
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_________________________ PSID
CLOSED TIGHT ..............
CHECK VALVE #1
1. LEAKED .................
______________________ PSID
2. CLOSED TIGHT ...........
CLEANED ...................
REPLACED ..................
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_________________________ PSID
CLOSED TIGHT ..............
DIFFERENTIAL PRV
OPENED AT _______________ PSID
DID NOT OPEN ..............
CLEANED ...................
REPLACED ..................
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
OPENED AT _______________ PSID
INITIAL TEST
REPAIRS – DOCUMENT
REPAIR DETAILS HERE
FINAL
TEST
THE ABOVE REPORT IS CERTIFIED TO BE TRUE
WHITE – Return to Public Works Department  YELLOW – Tester  PINK – Owner
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BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (city of san luis)

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Completed 16 July 2020

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