Fillable Form 1: SS 7 - Automatic Backflow Preventers (Invercargill City Council New Zealand)

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Form 1: SS 7 - Automatic Backflow Preventers (Invercargill City Council New Zealand)

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SS 7 - Automatic Backflow Preventers
Page 1 of 1
SBCG SS7 Version January 2018
T
he information above is used to help generate the compliance schedule. If you are unsure how to complete this
form, please consult an Independently Qualified Person (IQP) who is registered for the system above.
Address:
Building Name:
Provide by (name):
Make Model Location
1
2
3
4
5
6
7
8
9
10
Installation Standard:
AS 2845.3:2010
Specifically Designed Alternative Solution (please supply)
Other (Historical) _______________________________________
Inspections &
Maintenance
Standard:
AS 2845.3:2010
NZ Backflow Testing Standard
United States Environmental Protection Agency “Cross Control
Manual”
Specifically Designed Alternative Solution (please supply)
Other (Historical) _______________________________________
Frequency:
Annually
IQP
Inspections &
Maintenance:
Planned preventative maintenance and responsive maintenance shall be
carried out in accordance with the nominated performance and inspection
standard or document to ensure the system will operate as required.
Reporting:
The owner must keep records of all inspection, maintenance and repairs
undertaken in the previous 24 months. The records must be kept on site
and as a minimum, include:
• Details of any inspection, test or preventative maintenance carried
out, including dates, work undertaken, faults found, remedies
applied, and the person who performed the work.
• Details of any other faults found or maintenance and repair work
undertaken to maintain the system in working order, including dates,
work undertaken, faults found, remedies applied and the person
who performed the work
Supporting
Information:
• Attach technical data sheets for devices
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Form 1: SS 7 - Automatic Backflow Preventers (Invercargill City Council New Zealand)

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Completed 14 November 2020

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