PWS ID Water System Name File # Facility Name Non-Residential Residential Service Address City Zip Contact Person Phone Email Hazard Type (if known) DCVA RPBA PVBA AG Other Preventer Physical Location New Existing Replacement: Old Ser. # Confined Space Yes No Assembly Make Model Serial # Size ” USC-Approved Yes No Proper Install Yes No Proper Orientation Yes No DCVA RPBA PVBA/SVBA Initial Test Check Valve 1 Relief Valve Air Inlet Valve Leaked psid Passed Opened psid/ Not Open Opened at psid Did Not Open Check Valve 2 Failed Check Valve 2 Opened Fully Yes No Closed Tight Leaked Leaked psid Check Valve psid Check Valve 1 psid Leaked Approved Air Gap Yes No Cleaned Repaired Cleaned Repaired Cleaned Repaired Cleaning, Disc O-Ring(s) Disc O-Ring(s) Air Inlet Disc Float Repairs, & Spring Module Spring Module Air Inlet Spring Diaphragm Guide Rubber Kit Diaphragm Rubber Kit/Guide Check Disc Rubber Kit Parts Seat Seat Check Spring Check Valve 1 Relief Valve Air Inlet Valve Final Test Leaked psid Opened at psid Opened at psid Passed Check Valve 2 Opened Fully Yes No Check Valve 2 Closed Tight Failed Leaked psid psid Check Valve Check Valve 1 psid Pass Fail Air Gap Inspection Supply Pipe Diameter Air Gap Separation ” ” Line Pressure psi Detector Meter Gals CuFt Service Restored Yes No Remarks* Test Kit Make & Model Serial # Ver./Cal Date** I personally inspected and field-tested the backflow assembly using field test procedures meeting By this WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air signature, I gap or AVB. certify: The information in this report is true, complete, and accurate. BAT Signature (initial test) Cert. # Date/Time BAT Name (print) BAT Phone # Repaired By Date/Time BAT Signature (after repair) Cert. # Date/Time BAT Name (print) BAT Phone # BAT Company Name Address
PWS ID Water System Name File # Facility Name Non-Residential Residential Service Address City Zip Contact Person Phone Email Hazard Type (if known) DCVA RPBA PVBA AG Other Preventer Physical Location New Existing Replacement: Old Ser. # Confined Space Yes No Assembly Make Model Serial # Size ” USC-Approved Yes No Proper Install Yes No Proper Orientation Yes No Initial Test Passed Failed DCVA RPBA PVBA/SVBA Check Valve 1 Leaked psid Check Valve 2 Leaked psid Relief Valve Opened psid/ Not Open Check Valve 2 Closed Tight Leaked Check Valve 1 psid Approved Air Gap Yes No Air Inlet Valve Opened at psid Did Not Open Opened Fully Yes No Check Valve psid Leaked Cleaning, Repairs, & Parts Cleaned Repaired Cleaned Repaired Cleaned Repaired Disc O-Ring(s) Disc O-Ring(s) Air Inlet Disc Float Spring Module Spring Module Air Inlet Spring Diaphragm Guide Rubber Kit Diaphragm Rubber Kit/Guide Check Disc Rubber Kit Seat Seat Check Spring Final Test Passed Failed Check Valve 1 Leaked psid Check Valve 2 Leaked psid Relief Valve Opened at psid Check Valve 2 Closed Tight Check Valve 1 psid Air Inlet Valve Opened at psid Opened Fully Yes No Check Valve psid Air Gap Inspection Pass Fail Supply Pipe Diameter ” Air Gap Separation ” Line Pressure psi Detector Meter Gals CuFt Service Restored Yes No Remarks* Test Kit Make & Model Serial # Ver./Cal Date** By this signature, I certify: I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB. The information in this report is true, complete, and accurate. BAT Signature (initial test) Cert. # Date/Time BAT Name (print) BAT Phone # Repaired By Date/Time BAT Signature (after repair) Cert. # Date/Time BAT Name (print) BAT Phone # BAT Company Name Address
FldTstReport.docx