Fillable BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (City of Decatur Illinois)

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BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (City of Decatur Illinois)

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CITY OF DECATUR ILLINOIS
#1 GARY K ANDERSON PLAZA DECATUR, ILLINOIS 62523-1196
BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT
Customer’s Name
jon
Customer’s Address
Date
Manufacturer
Type
Model
Size
Backflow Device Address (If different than Customer’s Address)
Backflow Device Location
This Report is for:
Annual Test
New Installation
If New Device has been installed for Replacement-Record Previous S/N Below:
Reduced Pressure Devices
Pressure Vacuum Breaker
Double Check Devices
Air Inlet Check Valve
1
st
check
2
nd
Check
Relief Valve
Opened at
psi
Did not open
Closed Tight
Leaked
Initial
Test
DC-Closed Tight
RP- psid
Leaked
Closed Tight
Leaked
Opened at
psid
Repairs
and
Materials
used
Test
After
repair
DC-Closed Tight
RP- psid
Closed tight
Opened at
psid
Opened at
psid
Closed Tight
Tester’s Certification: The above is certified to be true.
Tester’s Name
Tester’s Number
Customer’s Certification:
The cross-connection control device detailed hereon has been tested and maintained as required by the Illinois
Environmental Protection Agency’s regulations and Water Services Division of the Public Works Department, and is certified to
comply with the current regulations. This device has not been by-passed, made inoperative or removed without proper
authorization. All defects found were satisfactorily corrected without delay. The above certified to be true.
Customer Certification
Date
Copy Distribution - Mail Original: Water Services Division, Dept of Public Works, #1 Gary K Anderson Plaza, Decatur, IL 62523
Copy to Owner and Copy to Tester
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BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT (City of Decatur Illinois)

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Completed 15 February 2021

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