CITY OF SURREY
Engineering Department – Water Section
13450 104 Avenue Surrey, BC V3T 1V8
Backflow Preventer Test Report
New Device and Previously Unregistered Device
Filled by Facility Contact Person:
Address of Assembly: ______________________________________________________Unit #: ________________
Business Name: ________________________________ Contact Person Name: __________________________________
Mailing Address (if different): _______________________________________________ Postal Code: ________________
Facility Type: Institutional Commercial Industrial Agricultural Single Family Multi-Family
Phone: _______________________________ e-mail Address: _______________________________________________
New Device Unregistered Device
Assembly Manufacturer: ___________________ Model: __________ Size: __________ Serial Number: ________________
Assembly Type: RP RPDA DCVA DCDA PVBA SVBA AG
Location of Assembly on Property, Building: ___________________________________
Assembly Orientation: Vertical Horizontal
Premise Isolation or if Individual Hazard, Specify Hazard Type: _________________
Test Equipment: Sight Tubes Diff Gauge
Gauge Make: ___________ Model: __________ Gauge Serial Number: ______________
Date of Calibration (YY/MM/DD): ___________Calibrated by: ____________________
Date of Initial Test (YY/MM/DD): ___________Test after repair date (YY/MM/DD):__________
RP/RPDA Initial Test Pass Fail RP/RPDA Test After Repair Pass Fail
1
st
Check Valve
Actual Press. Drop
____.____
2
nd
Check Valve
Closed Tight
YES NO
Relief Valve
Opened at:
____.____
Buffer
____.____
1
st
Check Valve
Actual Press. Drop
____.____
2
nd
Check Valve
Closed Tight
YES NO
Relief Valve
Opened at:
____.____
Buffer
____.____
Air Break > Diameter of the Relief Port of RPBA/RPDA (1” min.) Yes No
DCVA/DCDA Initial Test Pass Fail DCVA/DCDA Test After Repair Pass Fail
1
st
Check Valve
Press. Drop
____._____
Closed Tight
YES NO
2
nd
Check Valve
Press. Drop
____._____
Closed Tight
YES NO
Confirmation Test
1
st
CV Pass
Yes No
2
nd
CV Pass
Yes No
1
st
Check Valve
Press. Drop
____._____
Closed Tight
YES NO
2
nd
Check Valve
Press. Drop
____._____
Closed Tight
YES NO
Confirmation Test
1
st
CV Pass
Yes No
2
nd
CV Pass
Yes No
PVBA/SVBA Initial Test Pass Fail PVBA/SVBA Test After Repair Pass Fail
Air Inlet Valve
Opened at: _____._____
Opened Fully Yes No
Check Valve
Press. Drop _____._____
Closed Tight Yes No
Air Inlet Valve
Opened at: _____._____
Opened Fully Yes No
Check Valve
Press. Drop _____._____
Closed Tight Yes No
AIR GAP Pass Fail
Unobstructed Distance between Outlet to Rim of Receiving Vessel ≥ 2 x Diameter of the Discharge Outlet (1” min.) Yes No
Test Performed by: ____________________________________ BCWWA Certification No: ______________
Testing Company Name: ___________________________City of Surrey Business License No: ____________
Company Address: ____________________________ City: _________________ Postal Code: ___________
Company Phone: ___________________ Fax: _________________ Email: ____________________________
I certify that to best of my knowledge the information I have entered onto this form is complete and accurate. I
further certify that I have tested the above assembly in accordance with the current BC Water and Waste Association
Testing Procedures.
Tester’s Signature: __________________________________________________Date:______________________________
For Engineering use only.
Plumbing Permit Number
____________________
For Survey Required Device
Please indicate the item number from
the survey report _______.
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