Fillable Backflow Prevention Assembly Test Report

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Backflow Prevention Assembly Test Report

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  • 48 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Helena

BROWSE CITY OF HELENA (MT) FORMS

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BACKFLOW PREVENTION ASSEMBLY TEST REPORT
WATER CUSTOMER INFORMATION ASSEMBLY INFORMATION
NAME: ______________________________________________
MAILING ADDRESS: ____________________________________
CARE OF: ____________________________________________
CITY, STATE. ZIP: ______________________________________
ACCOUNT NO. _______________________________________
TYPE:_____________ SIZE: ___________ MFG: ____________
MODEL: _______________ SERIAL NO: ___________________
EXISTING - REFERENCE NO: ___________________________
REPLACEMENT - OLD ASSEMBLY SERIAL NO: _____________
NEW
TYPE OF SERVICE: DOMESTIC
IRRIGATION FIRE
MAILING ADDRESS CORRECTION REQUESTED
SERVICE ADDRESS __________________________________________________ CITY: ____________________________
ASSEMBLY LOCATION: _______________________________________________________________________________
(Please use dimensions and reference-Lot Lines, Property Lines, curb, other permanent features.)
INTERNAL: _________________________________________________________________________________________
(Please provide location. name of room, room number, unit number, or suite number if the device is an internal assembly.)
TEST RESULTS INFORMATION
DOUBLE CHECK VALVE ASSEMBLY
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
CHECK VALVE
N0. 1
CHECK VALVE
N0. 2
DIFFERENTIAL
RELIEF VALVE
AIR INLET VALVE CHECK VALVE
INITIAL
TEST
HELD AT:__________
PSID
LEAKED
HELD AT:__________
PSID
CLOSED TIGHT(RP)
LEAKED
OPENED AT:________
PSID
OPENED UNDER
2.0 PSID OR
DID NOT OPEN
OPENED AT:________
PSID
OPENED UNDER
1.0 PSID OR
DID NOT OPEN
HELD AT:__________
PSID
LEAKED
R
E
P
A
I
R
1)
CLEANED
REPLACED:
2) DISC
3) SPRING
4) GUIDE
5) SEAT
6) MODULE
7) OTHER
1)
CLEANED
REPLACED:
2) DISC
3) SPRING
4) GUIDE
5) SEAT
6) MODULE
7) OTHER
1)
CLEANED
2) EXERCISED:
REPLACED:
3) DISC(S)
4) SPRING
5) DIAPHRAGM(S)
6) SEAT(S)
7) 0-RING(S)
8) MODULE
9)
OTHER
1)
CLEANED
REPLACED:
2) DISC
3) DIAPHRAGM
4) FLOAT
5) OTHER
1)
CLEANED
REPLACED:
2) DISC
3) MODULE
4) OTHER
TEST
AFTER
REPAIR
HELD AT:__________
PSID
HELD AT:__________
PSID
CLOSED TIGHT (RP)
OPENED AT:________
PSID
OPENED AT:________
PSID
HELD AT:__________
PSID
INITIAL TEST TEST AFTER REPAIR COMMENTS:
START TIME: _________
END TIME: __________
DATE: ______________
START TIME: _________
END TIME: __________
DATE: ______________
ASSEMBLY: PASSED FAILED TAG NO:__________________________
MAIL
ORIGINAL
TO:
WATER UTILITY MAINTENANCE
316 North Park Avenue
Helena, Montana 59601
Jeff Feth 406-461-6679
CITY OF HELENA CERTIFICATION NUMBER __________________
PLEASE PRINT YOUR NAME: _____________________________
SIGNATURE: __________________________________________
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Backflow Prevention Assembly Test Report

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Completed 12 July 2020

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