City of Vancouver
Backflow Assembly Test Report
Business Name: _____________________________________________ Test Date:
Address of Assembly: _________________________________________ Strata #:
Business Owner or Contact Name
: ______________________________ Phone Number:
Assembly: New Portable If New, Plumbing Permit #:
Manufacturer: __________________ Model: ________________ Size: _______ Serial #:
Type: RPBA RPDA DCVA DCDA PVBA SVBA AG
Location of Assembly (Be Specific):
Premises Isolation Fixture (Be Specific): ________________________ Line Pressure (PSI):
Comments or Reason for Failure:
Test Performed by: ______________________________________________ Certification #:
Tester Company Name: __________________________________________ Phone Number:
Tester Company Address:
“I certify that I have tested the above assembly and that the test meets the performance requirements as
outlined in the City of Vancouver Waterworks Bylaw 4848”:
Tester’s Signature: _________________________ Business Owner/Contact Signature:
Return Completed Backflow Assembly Test Reports Within 30 Days of Test. email: backflow@vancouver.ca or
Print and Mail to:
Waterworks Design Branch
320 – 507 West Broadway, Vancouver, BC V5Z 0B4
Test Kit Serial Number:
Reduced Pressure Backflow Assembly
Initial Test
Static Pressure
Drop (A):
Relief Valve
Opened at (B):
Closed Tight
Buffer (C)
(A-B=C)
_________ PSID _________ PSID Yes No
Test After Repair _________ PSID _________ PSID
Yes
No
Is Minimum Air Gap Requirement Provided on the RPBA
Yes No
Double Check Valve Assembly S or P Vacuum Breaker Assembly
Initial Test
1st Check 2nd Check
Opened at:
Held at:
Test After Repair _________ PSID
_________ PSID
Opened at: Held at:
__________________
