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FULTON COUNTY BACKFLOW-PREVENTION ASSEMBLY TEST DATA & MAINTENANCE (Fulton County Government)

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FULTON COUNTY
DEPARTMENT OF PUBLIC WORKS
BACKFLOW-PREVENTION
“a community-environmental
health protection program
”
ASSEMBLY TEST DATA & MAINTENANCE REPORT
A
ccount N
ame:
(Name of Premise)
Contact Name:
Mailing Address:
(Owner/Agent)
Telephone #:
Service Address:
(Premise)
Meter No.:
Location of Assembly: Installation Date:
Type of Assembly: Manufacturer: Model: Size: Serial No.:
Date of Test: Time of Test:
AM PM
Initial Test ¤
New ¤ Retrofit ¤
Semi Annual
Test:
Annual
Test:
Other Test – List:*
(i.e., repair re-test)
Dom: Fire: Combo: Irrigation: Other: Line pressure at time of
test ____________psig
Apparent pressure drop across
check valve No.1 _________psig
CHECK VALVE NO. 1 CHECK VALVE NO. 2
DIFFERENTIAL
PRESSURE RELIEF
VALVE
PRESSURE VACUUM
BREAKER
1. Leaked _
___________ ¤
2. Closed at ______psid ¤
Passed ¤ Failed ¤
1. Leaked ____________ ¤
2. Closed at ______psid ¤
Passed ¤ Failed ¤
1. Opened at ______psid ¤
2. Did not open_______ ¤
Passed ¤ Failed ¤
1. Air inlet opened at
________psid ¤
2. Did not open_______ ¤
Passed ¤ Failed ¤
R
E
P
A
I
R
S
Cleaned
______________ ¤
Replaced:
Disc. _____________ ¤
Spring ____________ ¤
Guide _____________ ¤
Pin retainer ________ ¤
Hinge pin __________ ¤
Seal ______________ ¤
Diaphragm _________ ¤
“O” rings __________ ¤
Test cocks _________ ¤
#1 _____ #2 _____
Complete repair kit __ ¤
Other, describe _____ ¤
Cleaned ______________ ¤
Replaced:
Disc. _____________ ¤
Spring ____________ ¤
Guide_____________ ¤
Pin retainer ________ ¤
Hinge pin _________ ¤
Seal ______________ ¤
Diaphragm ________ ¤
“O” rings _________ ¤
Test cocks _________ ¤
#3 _____ #4 _____
Complete repair kit __ ¤
Other, describe _____ ¤
Cleaned ______________ ¤
Replaced:
Disc. _____________ ¤
Spring ____________ ¤
Diaphragm _________ ¤
Spacer ____________ ¤
“O” rings __________ ¤
Seat ______________ ¤
Complete repair kit __ ¤
Other, describe _____ ¤
Check Valve:
Leaked at _____psid ¤
Closed at _____psid ¤
Cleaned ______________ ¤
Replaced:
C.V. assembly. _____ ¤
Disc. Air inlet ______ ¤
C.V. disc __________ ¤
Spring ____________ ¤
Retainer __________ ¤
Guide ____________ ¤
Bonnet ___________ ¤
Other, describe _____ ¤
*
Date: Time: AM PM Line pressure at time of test _______psig
FINAL
TEST
Closed at
______psid ¤
Passed ¤ Failed ¤
Closed at ______psid ¤
Passed ¤ Failed ¤
Opened at ______psid ¤
Passed ¤ Failed ¤
Passed ___________ ¤
Failed ____________ ¤
BFP test kit: Manufacturer: Model #: Serial number: Calibration exp date: Company:
Remarks:
I hereb
y certify that this data is accurate (true) and reflects the proper operation, test, and /or maintenance of this assembly.
Tested by: (print)
Repaired by: (print) Signature:
Final test by: (signature)
Training
certification no: Certification expiration date:
TURN WATER ON
¤
¤¤
¤
Please sav
e a completed copy of this form and email to: Jason.Depas@fultoncountyga.gov
**Please sign below where directed by clicking on the signature tool in the tool bar and following the instructions to place a signature.**
**FIELDS IN RED ARE REQUIRED**
Fulton County
Department of Public Work
Backflow Prevention Section
11575-A Maxwell Rd.
Alpharetta, GA 30009
Phone (770) 410-3421
Fax (404) 893-1896
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FULTON COUNTY BACKFLOW-PREVENTION ASSEMBLY TEST DATA & MAINTENANCE (Fulton County Government)

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Completed 6 August 2020

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