Fillable Back Flow Device Test Report Form (City of West Columbia, SC)

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Back Flow Device Test Report Form (City of West Columbia, SC)

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The Back Flow Device Test Report Form (City of West Columbia, SC) form is 1 page long and contains:

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  • 19 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of West Columbia, SC

BROWSE CITY OF WEST COLUMBIA, SC (SC) FORMS

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Back Flow Device Test Report Form
Account Name/Business Name: _____________________________________________ Date: _________________
Account Address: _________________________________________________________________________________
Account Number: _____________________________________ Meter Number: ____________________________
Device Name: ______________________________________ Device Type: DC:____ RPV: ____ Dual Check:____
Model Number: ________________________ Serial Number: ______________________ Size: _______________
Tested By (Print): ________________________________ Device Location: ________________________________
Above data certied to be correct.
Tester Signature: _________________________________________ Certication Number: ____________________
Company Name: __________________________________________ Phone Number: _______________________
Category: _____________________ General: ___________________ Limited: ______________ Inspector Tester
Method of Testing: ______________________________________ Test Kit Used: ____________________________
Comments: ______________________________________________________________________________________
__________________________________________________________________________________________________
200 N. 12th Street • PO Box 4044 • West Columbia, SC 29171-4044 • (803) 791-1880 • FAX: (803)-739-6231
Test
Before
Repairs
Test
After
Repairs
Repair and
New Materials
Check No. 1 Check No. 2
Air-Inlet Valve
or Relief Valve
#1 Gate or Ball
(Circle One)
#2 Gate or Ball
(Circle One)
(Mark One)
Leaked _______
Closed Tight _______
(Mark One)
Leaked _______
Closed Tight _______
Di Press
Di Press
(Mark One)
Leaked _______
Closed Tight _______
(Mark One)
Leaked _______
Closed Tight _______
Di Press
Di Press
Opened at
________________ lbs.
Dierential Pressure
Opened at
________________ lbs.
Dierential Pressure
(Mark One)
Leaked _______
Closed Tight _______
(Mark One)
Leaked _______
Closed Tight _______
(Mark One)
Leaked _______
Closed Tight _______
(Mark One)
Leaked _______
Closed Tight _______
PASS ________________________________ FAIL ________________________________
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Back Flow Device Test Report Form (City of West Columbia, SC)

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Completed 17 July 2020

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