backflow device test report form

Fill out the test report completely, write legibly and in ink 2. 7:10-10.6 / / the Backflow Prevention Device listed on this form was functioning satisfactorily at the time of the test. Backflow Prevention Program. The backflow prevention device details, such as device model, serial number, site address, etc. Backflow Device Test Form - 06-2016. Atlanta, GA 30303. Backflow Prevention Section . BACKFLOW DEVICE TEST REPORT FORM Inspector Tester The above data certified to be correct. StLCO Form: Test Rpt 0305b C:\Documents and Settings\pw0l0b.000\Desktop\0305b Backflow Form.doc BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT Customer: Mailing Address: City and State: Zip Code Address of Location of Back-Flow Device: Describe physical location of Back-Flow Device: Test report books are printed in triplicate (original, pink and yellow copies) and cost $10 for a book of 25 forms. The backflow device is to be tested and the completed test form is to be returned to Public Works/Field Services Division at 17300 Mt. This ready to use backflow prevention device test form goes through all required testing items, checking all valves and inlets. Town of Lexington Utilities Department. Tester Signature: _____ Certification Number: _____ Company Name: _____ Phone Number: _____ Quarterly Physical Connection Test & Maintenance Report. Get started now. Testers and customers can send any documents regarding backflow questions or issues to [emailprotected] Environmental Compliance Section. Push theGet Form Button below . Please fill in all of the following information on the Backflow Device Test Report Form: Date: Author: opaulasantos Created Date: 06/23/2020 09:21:00 Title: BACKFLOW PREVENTION DEVICE REPAIR INFORMATION & Last modified by: Yano, Tio (DEP) # Complete block and lot (if available) for New York City Metropolitan area tests. KC Water Blank Prevention Assembly Test Report. Phone: 404-546-3239. What Is Backflow? DATE BACKFLOW DEVICE TEST REPORT SUPPLY LINE _____ PSI Check Valve #1 Check Valve #2 Differential Pressure Relief Vacuum Breaker If assembly fails test, complete this section and note repairs: (If Device replaces an existing device, list Serial # of existing device.) Backflow Prevention Device Testing Requirements. 1. EACH TEST REQUIRES A $17.00 SUBMISSION FEE. BACKFLOW ASSEMBLY TEST REPORT Name: Address: Mailing Address: Location of Device: Manufacturer: Model of Device: Serial Number: Size of Device: Type of Device: Check Valve No. Form GEN-215B must BACKFLOW DEVICE TEST REPORT . Therefore, signNow offers a separate application for mobiles working on Android. Backflow Prevention Device Test Report To be submitted by the Property Owner, or Agent of an Industrial, Commercial, Institutional, or Multi-Residential building. Backflow Prevention Device Test Report To be submitted by the Property Owner, or Agent of an Industrial, Commercial, Institutional, or Multi-Residential building. xc2 software backflow test form examples. Once you have reviewed the instructions above, you may proceed to create an account or login through the Online Licensing Portal. To avoid delays in receiving the completed test form, e-mail is the preferred delivery method. 72 Marrietta Street. Service Address Name of Premises Location of device DCDA RPDA Reduced Pressure Principle Assembly . Backflow Device Test Report Form Mail Original & $10 Filing Fee to City of Goddard City of Goddard 118 North Main, PO Box 667 Goddard, KS 67052 P: 3167942441 F: 3167942401 PROPERTY INFO Owner. Please return completed form by mail or fax to Pennsylvania American Water: Fax: 570-341-3296; Email: [emailprotected]; or Mail: Attention: Cross Connection Department 2699 Stafford Ave Scranton, PA 18505. To find it, go to the App Store and type signNow in the search field. Plumber's Name (please print) Plumbers License # Telephone # Signature. Stafford, Virginia 22554. Backflow Prevention Device Test Report . : Size: Line Pressure at time of test: (psi) Date Installed: Date Overhauled: Date Tested: Backflow\Backflow Test Report Form. Title: Back Flow Device Test Report Form Author: Mark VanDevender Subject: Back Flow Device Test Report Form Keywords: Back Flow Device Test Report Form Air-Inlet Value or Relief Valve #1 Gate or Ball (Circle One) (Mark One) #2 Gate or Ball (Circle One) (Mark One) Check No. Backflow Prevention Device Test Form. 7-10, 2022 Submitting boundary containment backflow test reports is fast and easy with our online lodgement system. Second check is The backflow prevention device identified below has been tested and inspected as required by N.J.A.C. Appendix G: BPCCC Non Community Program and Report Template. 2809 S. Lynnhaven Road Suite 250. [emailprotected] (805) 200-5374. Indicate the date to the template using the Date tool. STATE FORM 55788, BACKFLOW DEVICE TEST 327 IAC 8-10-9(b) TYPE OR PRINT ALL ENTRIES. How to create an electronic signature for the SADEC Backflow Test Report Form on Android devices backflow test form pdf, the market share of Android gadgets is much bigger. A cross-connection is an actual or potential link connecting a source of pollution or contamination with a potable water supply. backflow prevention assembly test report form. Backflow Prevention and Cross-Connection Control. : Size: Line Pressure at time of test: (psi) Date Installed: Date Overhauled: Date Tested: Backflow\Backflow Test Report Form. Date. Test results must be submitted to the Town's Utilities Department using this Backflow Test Report Form. The Backflow Device Test Report Form (City of West Columbia, SC) form is 1 page long and contains: 0 signatures; 32 check-boxes; 31 other fields; Country of origin: US File type: PDF U.S.A. forms for City of West Columbia, SC Last updated February 15, 2022. Water Division. Virginia Beach, Virginia 23452. This form report is for the test of an Internal (Secondary) Backflow Prevention Device and must be submitted to the Department of Buildings ONLY. Fax 540-658-1088. ALL BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE FORMS MUST BE SUBMITTED TO MAWC. the . Appendix F: Alternative Survey Compliance Ratio Application. Fax: (813) 635-1612. If you use the PDF form, submit test and maintenance results by one of the following methods: Scan and email. Backflow Preventer Test Report I:\DEVELOPMENT\ConstSvcs\FORMS a nd INFO OUT\Current Handouts\Form - Backflow Preventer Test Report 75.pdf . Herrmann Street, Fountain Valley, CA 92708-4104 or e-mailed to [emailprotected] Click here for the Fountain Valley's Backflow Test and Maintenance Report Form. Ahmad Cade, Backflow Manager. A Backflow Prevention Device Repair Information & Re-test Report Form must be completed to report the repair(s) conducted and to report the re-test result. If you need assistance applying for, or renewing your registration online after reviewing the above instructions, please contact the Help Desk at 855-824-4357 or email [emailprotected] Here you would be transferred into a splasher that allows you to make edits on the document. Des Moines Water Works attn. Form must be completely filled out to be accepted. Lodge backflow test report. MUST BE COMPLETED BY THE TESTER IN INK. signNow has paid close attention to iOS users and developed an application just for them. To sign a new backflow test sheet form right from your iPhone or iPad, just Commercial and residential customers are responsible for submitting annual backflow test results to the Town. : Company Name: Contractor License No. Fill out every fillable area. Neighborly. 1 Check Valve No. Indicate the Service Use of the backflow device. Backflow devices must be tested at the time of installation and annually. Backflow Prevention Device Test Report City of Martinsville Customer ID Number; Name of Premises_____ Certification: I have made the above test and hereby certify that this backflow prevention device performed satisfactorily and meets all federal, state and local codes and regulations as required. CITY OF HUNTINGTON BEACH WATER DEPARTMENT BACKFLOW DEVICE TEST REPORT Return completed form by e -mail to . Serial No. Below you can get an idea about how to edit and complete a Backflow Prevention Device Test Report conveniently. Above data certified to be correct. This test report form is for PREMISE ISOLATION ONLY and tests must be conducted by a certified tester under Schedule Check Valve #1 No. backflow testing services inc illinois backflow testing. A Complete Guide to Editing The Backflow Prevention Device Test Report. Print Name Signature Final Test By: Company Tester Ph. A backflow testing report will document the type of testing conducted and the status of the pipes. Phone: 803-951-4651. Annual Test/Re-Certification: Complete parts A and B only . Please enter the numbers before the dash; do not include the dash. IF REPAIRS TO BACKFLOW PREVENTION DEVICES ARE NECESSARY, THE SERVICES OF A LICENSED CONTRACTOR MAY BE REQUIRED. Test Done By (Please Print First & Last Name): Certificate No. Backflow Prevention. Each backflow device must be tested by a New York State Certified Backflow Prevention Device Tester and a test report (FORM GEN-215B) certifying that the backflow prevention device is operating properly must be submitted by the owner, within 30 days of the test, to the DEP. Leaked It will need to be submitted to the construction site for continued building. TESTS AND REPAIRS INFORMATION An option to create a pdf report of the backflow prevention device test on the spot, on a smartphone or tablet. The purpose of form TCEQ-20700 Backflow Prevention Assembly Test and Maintenance Report (T&M Form) is to document the results of testing a backflow prevention assembly. ALL TESTING MUST BE CONDUCTED IN ACCORDANCE WITH METHODS CURRENTLY APPROVED BY CITY OF ANDERSON 1 ELECTRIC CITY UTILITIES AND THE SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL (SC DHEC). BACKFLOW DEVICE TEST REPORT FORM. THE ABOVE REPORT IS CERTIFIED TO BE TRUE Device Test Data Maintenance Report : Author: Backflow Prevention Device Test Report. 1. st. Quarter 01/01-03/31 2. nd. Fax: 803-358-1535. The backflow prevention device identified below has been tested and inspected as required by N.J.A.C. Download the form to your computer and open it up with a PDF viewer, such as Adobe Acrobat Reader. Check Valve No. Backflow takes place when water in a distribution system flows in the opposite direction from what is normal. A partial listing of common cross-connection hazards: Table Listing Common Cross-Connection Hazards (290.47(f)) Email original test report to [emailprotected] or mail the original completed test report form to: City of Fullerton Engineering Department It will need to be submitted to the construction site for continued building. Share & Bookmark Share & Bookmark, Press Enter to show all options, press Tab go to next Twitter; Reddit; Font Size: +-Backflow Prevention Device Test Report Form. Tester Signature: _____ Certification Number: _____ Company Name: _____ Phone Number: _____ Line Pressure a Time of Test _____ psi. Initial Test and Certification: Complete all 4 parts. Telephone: 416-394-8888 (Voicemail Only) Email: backflow@toronto.ca. backflow test formke an iPhone or iPad, easily create electronic signatures for signing a new backflow test sheet form in PDF format. Test reports can be picked up at our office. CITY OF HUNTINGTON BEACH WATER DEPARTMENT BACKFLOW DEVICE TEST REPORT Return completed form by e -mail to . Meter numbers and/or other pertinent information must be submitted . I have made the above test and hereby certify that this backflow prevention device Mail forms to: PO Box 246, Smithfield, VA 23431 Attn: Backflow Administrator. Implementation Steps. 1 Check No. [emailprotected] or mail to: City of Huntington Beach, Attn: Utilities Div. C&L Plumbing is a father and son family operated full service professional backflow prevention service. Email New or Replaced backflow assembly test forms to [emailprotected]arlingtontx.gov. Check Valve #1 No. REPAIRED BY DATE Signature FINAL TEST BY Signature Print Signature CERTIFIED TESTER NO. Suite 201. John Lins 2201 George Flagg Pkwy Des Moines, IA 50321 Phone 283-8775 Fax 283-8723 Send to: backflow@dmww.com. The form can be completed in one of two ways: The form can be printed and completed by hand, or. PRESSURE VACUUM BREAKER Requirements Initial Test Repairs Retest Air Vent Opened at Min . of 1.0 psid Yes No psid Yes No psid Check Valve Opened at Min . Test Report Books Effective April 18, 2016, photocopies of backflow test reports will no longer be accepted and backflow technicians are required to purchase test report books from the Public Works Department. Backflow Prevention Device Repair Information & Re-test Report Form. Title: OP129: Report on Testing of Internal (Secondary) Backflow Prevention Device Your customer number is provided on the backflow notifications and also in the upper right-hand corner of your water bill. must be filling out. Backflow Test Form (PDF) Records of such tests, repairs and overhauls must be provided to the City of Fullerton and the County of Orange Health Care Agency for their respective permanent files. In addition they are required to submit a tester information sheet and provide evidence of backflow prevention assembly tester certification from either the California-Nevada Section of the American Water Works 275 Merton St. Toronto, ON M4S 1A7. GENERAL INFORMATION. backflow prevention assembly test report (for field use only) install/tester id: permit # account #: (acc # not required) name of premises: commercial residential service address: city: zip: contact person: phone: county: mc pg location of assembly: MUST BE COMPLETED BY THE TESTER IN INK BACKFLOW DEVICE Phone 283-8775 Fax 283-8723 Send to: backflow@dmww.com TEST REPORT. (Form BF-1) I. Appendix C: Cross-Connection Control Extension Application. 2407 Backflow Prevention Device Test and Maintenance Report NO ENDORSEMENT IS INTENDED. TO PAY BY CREDIT CARD PLEASE CALL CUSTOMER SERVICE @ 724-755-5800, OR SUBMIT BY MAIL TO PO BOX 730, GREENSBURG, PA 15601 AND INCLUDE THE $17.00 Backflow Assembly Test Form. Customer or Denver Water Backflow Assembly Test & Maintenance Report (please print CLEARLY with BLOCK LETTERING) Testing Company: Submit by e-mail (preferred) to [emailprotected], type "Backflow Test Reports" in the subject line OR submit by Fax to (303) 794-8325. Print Feedback. Step One. Backflow Preventer Test Form Lincoln Water System Backflow, 2021 N 27th St, Lincoln, NE 68503 . # Complete public water supply name, customer account number (if available) and county. Testers who want to be included on the Cal Water tester resource list must attend a Backflow Tester Meeting. Contact Information. [emailprotected] or mail to: City of Huntington Beach, Attn: Utilities Div. Backflow Prevention Assembly Test and Maintenance Report (TCEQ Form 20700 Word) / (TCEQ Form 20700 PDF) This report is used to document the results of testing a backflow prevention assembly for proper functioning. 684 Winder Hwy TESTED BY: Lawrenceville, GA 30045 (678) 376-4213 . Appendix B: BPCCC Example Ordinance. There are 3 options; typing, drawing, or uploading one. The Backflow Prevention Program Report was approved by Council on June 28, 2017. Box 337 Stn. backflow@vbgov.com . 1. Box 337 Stn. Report on Test and Maintenance of Containment Backflow Prevention Assembly (FORM GEN215B) Use a separate form for each particular assembly Indicate Initial Test or Annual Test by checking the appropriate choice. An annual test has been completed: Contact the contractor who completed the test and ask them to complete the test submission. Phone: 402.441.5912 Fax: 402.441.8003 e-mail: Backflow@lincoln.ne.gov. After testing the device, a copy of the results must be faxed to the City of Aiken Backflow Prevention Officer. The information supplied to Council from the initial Form 9 test report submitted by the plumber is recorded in the Backflow Register. Property owners will receive a reminder of their Tester Signature: Date: City Utilities 265 Lexington Court P.O. - CC P.O. Get Backflow Device Test Report Form - Goddardksgov. Test kit number Certification date of calibration / / Testers name License number Phone Testers signature Contractors business name or stamp Date / You must forward the completed form within 7 days to - This test report form is for . Facility Information. Appendix E: BPCCC Survey and Questionnaires. The following numbers refer to the enclosed form. Backflow Prevention Device Test Report To be submitted by the Property Owner, or Agent of an Industrial, Commercial, Institutional, or Multi-Residential building. Service Address Name of Premises Location of device DCDA RPDA Reduced Pressure Principle Assembly . Backflow Tester Resource List. REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE PART A - To Be Completed by Certified Tester # Indicate the test year and whether initial or annual test. ATTN: Backflow Program PU Engineering. of 1.0 psid Yes No psid Yes No psid Remarks: Certification: I have made the above test and hereby certify that this Backflow Prevention Device Backflow is the undesirable reversal of flow in a potable water distribution system through a cross-connection. Waterloo Waterloo ON N2J 4A8 T 519-886-2310 x 30231 F 519-886-5788 Email: [emailprotected] Email . This test report form is for . testing of backflow prevention devices registered air. Relief Valve Opening Point Check Valve # 2 Backpressure Test . Backflow Preventer/Assembly. We have been proudly serving the San Francisco Bay Area since 1999, and have a combined total of 25 years of experience in both plumbing and fire sprinkler services. Whether youre a plumber or the construction site manager, use this free Backflow Test Form template to streamline your backflow testing protocol! P://OPS/Xconn/Repair & Re-test Form #10 rev 2018-03-20. Date: Account Name/Business Name: Account Address: Account Number: Meter Number: Device Name: Model Number: Serial Number: Size: Device Location: Tested by (PRINT): Reduced Pressure Backflow Device. Training and Certification of Backflow Prevention Device Testers: Newington, Mar. Backflow Type: (Please circle backflow type) Contamination or Isolation _____ Date Backflow Device was tested:_____ Double Check Valve Reduced Pressure Principle Pressure Vacuum Breaker Check Valve #1 Check Valve #2 Check Valve #1 Check Valve #2 Relief Valve Air Inlet Valve Check Valve Initial Test Closed Tight A backflow testing report will document the type of testing conducted and the status of the pipes. Relief Valve Opening Point Check Valve # 2 Backpressure Test . This form shall be used for backflow devices required under 327 IAC 8-10, which typically are containment protection applications. Above data certified to be correct. COMMERCIAL systems will remain on the annual testing schedule. If there is a specific problem relating to the test or the test report form, the tester must call the water agency or the County Health Department. Be sure the details you fill in NEWWA Backflow Prevention Device Assembly Test Report Form is up-to-date and accurate. : Size: Assembly Type: RP RP Detector DC Detector PVB II. gutscheinscheibe de. Tester Signature: Date: City Utilities 265 Lexington Court P.O. The following table lists upcoming training courses offered by the New England Water Works Association (NEWWA) that have been approved by the Department of Public Health for the testing of backflow prevention devices. The Backflow Test Date: _____ Plumbing Permit No: _____ CITY Plumbing Inspection Section 805 Central Ave, 5th Floor Cincinnati, OH 45202 Backflow may allow liquids, gases, non-potable water and other substances from any source, to enter a public water system. Backflow Assembly Test Report Phone: 651-714-3720 Fax: 651-714-3721 E-mail: [emailprotected] Business Name: Site Address: Device Location: Isolates What System: Make: Model: Serial No. The test form must be completed and signed by an individual certified in backflow device testing. [emailprotected] please return test results by insert date. Backflow Assembly Test Report Phone: 651-714-3720 Fax: 651-714-3721 E-mail: [emailprotected] Business Name: Site Address: Device Location: Isolates What System: Make: Model: Serial No. Whether youre a plumber or the construction site manager, use this free Backflow Test Form template to streamline your backflow testing protocol! [emailprotected] Physical and mailing address: 2128 Richmond Hwy. 2 Shutoff Valve Check Valve #2 : Opened at _____ psid : Did not open Closed Tight Leaked Held at _____ psid . AS2845 requires test equipment used for field testing backflow prevention devices shall be annually calibrated by a registered laboratory. 1 Check No. BACKFLOW DEVICE TEST REPORT FORM Date: _____ Business Name: Address: Account Number: Meter Number: Device Name: Model Number: Serial Number: Size: Device Location: Type of Line: Domestic Irrigation Fire Line Fire Line Bypass Other Check No. 1-4, 2022; Newington, Jun. Reports missing information may be returned. Hand Deliver or US Mail . Any RESIDENTIAL irrigation sprinkler system installed AFTER June 13, 2000 must have a testable device that is tested bi-annually. Backflow Preventer Test Report I:\DEVELOPMENT\ConstSvcs\FORMS a nd INFO OUT\Current Handouts\Form - Backflow Preventer Test Report 75.pdf . Mail: # Registration No Registration Date: Expiration Date: THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE TEST REPORT BACKFLOW DEVICE Initial Test After Repair PVB/ SVB Below portion must be completed by tester H:\BACKFLOW\Brochures.docs.forms\Backflow Test : City: State: Zip: Contact Person/Phone No: Completed Test and/or Rebuild Report Appendix D: BPCCC Annual Report and Tracking Template. Observe gauge and record on test form. Contractor may use their own version and must have the same information as the City's form. Backflow Device Test Witnessed by. NEWWA Backflow Test Report Form (Writable PDF Format) Upcoming Courses & Brochures. 5th Floor. E-Mail: [emailprotected] Backflow Device Test Report Form. PO BOX 397 Lexington SC 29071. P://OPS/Xconn/Inspection & Maintenance Report Form #8 rev.2018-03-20 BACKFLOW PREVENTER INSPECTION ANDASSEMBLY Initial Test Initial Test MAINTENANCE REPORT FORM(Print Clearly) Information. An annual test ensures the backflow devices is in good working order and prevents unwanted water from entering the drinking water supply. The form can be completed electronically through an electronic medium (tablet, laptop It allows backflow testers to lodge boundary containment backflow test reports online, making reporting an efficient and effective process that will benefit both our customers and testers. Waterloo Waterloo ON N2J 4A8 T 519-886-2310 x 30231 F 519-886-5788 Email: [emailprotected] Quarter 07/01-09/30 4. th. December 1, 2021 - ALL BACKFLOW PREVENTION DEVICE INSPECTOR/TESTER CERTIFICATIONS THAT EXPIRE IN 2020 AND 2021 ARE EXTENDED TO MARCH 31, 2022 - THIS IS THE LAST EXTENSION THAT WILL BE GRANTED. Address: FMSS Asset ID Number: Location of Assembly: Date of Installation: Incoming Line Pressure: Manufacturer: Model No. Sun, May 29, Partly Cloudy, 68F. 2 (Mark One) (Mark One) (Mark One) (Mark One) G)MMISSION WQ S Reliable. Orientation (PVB) Air Inlet (RP) Type Of Use (RP, DC, PVB) INITIAL TEST BY DATE Signature CERTIFIED TESTER NO. Seal. The purpose of the Cross Connection Program is to protect the City of Arlington water supply system by eliminating potential sources of contamination resulting from illegal cross connections and backflow. - CC P.O. Email completed test reports to: backflow@staffordcountyva.gov. MUST BE COMPLETED BY CERTIFIED BACKFLOW DEVICE TESTER. The above report is certfied to be true as attested herein. Fax: 404-235-2054. Backflow Tester Registration. Quarter 04/01-06/30 3. rd. You may contact the City to find information about the last recorded test, including the test date and contractor, by calling (316) 265-1300 or by emailing backflow@wichita.gov. test a device and generate a backflow report in 30 seconds. hereby certifies that through a site inspection and witnessing of a pressure test. If the device is used for isolation with test report. FM 266-114 Rev date: 1/11/12 LOUISVILLE WATER COMPANY Fax to: Louisville Water Company Att: Cross Connection Control Fax (502) 569-0848 Phone (502) 569-3600, ext. Select the Sign button and make an electronic signature. : Company Address: Company Phone No. BACKFLOW DEVICE TEST REPORT . REDUCED PRESSURE DEVICE: REQUIREMENT INITIAL TEST REPAIRS RETEST. It is the responsibility of the company performing any RBA related work to complete and submit a RBA Test Report with appropriate payment to the City within two weeks of work completion. Date. Backflow Device Test Report Form FAQs. All backflow device test reports must be submitted to the water purveyor and the County Health Department within 10 days of the initial test, no matter what the result. 2 Shutoff Valve Check Valve #2 : Opened at _____ psid : Did not open Closed Tight Leaked Held at _____ psid . Leaked If assembly fails test, complete this section and note repairs: (If Device replaces an existing device, list Serial # of existing device.) City Of Virginia Beach. Section 78 Article V of the Kansas City Code of ordinances requires annual operational rest and certified inspection of all backflow devices. BACKFLOW PREVENTION DEVICE TEST REPORT Please return report to: Medina County Sanitary Engineers Backflow Prevention Program 791 W. Smith Road Medina, OH 44256 Email: mcse_backflow@medinaco.org Fax: (330) 764-8589 Attn: Backflow Prevention Program Please enter all information as completely and as accurately as possible. Contact us with backflow questions at backflow@gardnerkansas.gov. Service.