Fillable Backflow Prevention Assembly Test Report

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Backflow Prevention Assembly Test Report

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The Backflow Prevention Assembly Test Report form is 2 pages long and contains:

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  • 28 check-boxes
  • 120 other fields

Country of origin: CANADA
File type: PDF

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Name of Property Commercial Residential
Street Address
Contact Person Tel Fax
Location of Assembly
Type of Assembly
RPBA DCVA PVB RPDA DCDA AG Testing Equip: DIFF DUP ST
Initial Test Performed by Cert. No. Date (YMD)
Business Name
Business Address Postal Code
Business Phone
** IF ASSEMBLY FAILS INITIAL TEST, COMPLETE REVERSE SIDE OF WHITE COPY **
I CERTIFY THAT I HAVE TESTED THE ABOVE ASSEMBLY AND THAT IT MEETS THE PERFORMANCE REQUIREMENTS OUTLINED IN THE
CITY OF BURNABY PLUMBING BYLAW
Tester’s Signature Owner’s Representative - Please print name and sign
Q:\Forms\Forms for the WEB Revised: 2014 January 23
New Installation Permit No.
Existing Replacement
Serial number of OLD assembly
Line pressure at time of test p.s.i.
Reduced Pressure Assemblies Pressure Vacuum Breaker
Air Intake
Check Valve
Double Check Assemblies
First Check (A)
2nd Check
Relief Valve (B)
Buffer (a-b=c) (C)
Opened at
Pressure Drop
Did not open Leaked
Opened at
Closed tight
No
Leaked
Passed
Failed
DC closed tight
RP actual pres drop
Confirmation test Yes
Leaked
DC closed tight
Confirmation test
Yes
Air Gap Inspection: Required minimum air gap separation provided Yes No
Equipment or Zone Isolated
Manufacturer (Make) Model Serial No. Size
Assembly
psid
RP actual pres drop
psid
TEST REPORT MUST BE SUBMITTED NO LATER THAN 10 DAYS FOLLOWING TESTING
psid psid
psid
psidpsidpsid
Opened at
Closed tight
psid psid
TEST AFTER REPAIR INITIAL TEST
Opened at
Pressure Drop
psid
psid
4949 Canada Way, Burnaby, BC V5G 1M2
Cross Connection Control
Telephone: 604-294-7542 Fax: 604-570-3608 www.burnaby.ca/building Email: crossconnectioncontrol@burnaby.ca
Backflow Prevention Assembly Test Report
Page 1 of 2
Reset Form
Description No. 1 Check
Valve
No. 2 Check
Valve
Relief Valve
1.
Isolating Gate Valve(s) Passing Water
2.
Foreign Matter Introduced During Construction
3.
Sand or Grit Inherent to the Supply System
4.
Copper Filings Solder or Pipe Dope
5.
Nuts, Bolts, Washers, etc. (not from assembly)
6.
Paper, Cardboard or Sawdust
7.
Improper Assembly Installed
N/A N/A
8.
Kinking of External Sensing Line
9.
Air Entrapment
10.
Turberculation or Rust
11.
Frozen Assembly
12.
Abnormal Rubber Disc Wear or Cuts
13.
Spring(s)
14.
O Ring(s)
15.
Loss of Interior Coating
16.
Disc Retainer (Fractured or Worn)
17.
Retain Nut
18.
Improper Casting or Machining of Assembly
19.
Guide Mechanism
20.
Obstructed Sensing Line
N/A N/A
21.
Diaphragm Failure
N/A N/A
22.
Replace Rubber Parts
23.
Test Cock(s) Missing from Assembly
N/A
24. Improper (Unapproved) Installation
25.
Assembly no Longer Required
26.
Assembly Replaced
27.
Couldn’t Test (Explain below)
28.
Vertical Installation Yes
No
N/A N/A N/A
29.
Remarks
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Check Causes for Backflow Preventor Failing Initial Test
Other (please specify)
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Page 2 of 2
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Backflow Prevention Assembly Test Report

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Completed 26 July 2021

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