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Reduced Pressure Type Double Check Type Retest Leak Leak Leak Tightness Tightness Tightness Check Check _ Tight Air #1 PSI #1 _Leaked --PSI Inlet --PSI Check _Tight Check _Tight Check _Tight #2 Leaked PSI #2 Leaked PSI #1 Leaked PSI Relief Pressure Vacuum Breaker Check _ Tight Valve PSI #2 _Leaked --PSI Buffer Leak Relief Zone --PSI Tightness Valve --PSI Shutoff Valve 1 _ Tight Air Inlet Buffer _Leaked Open --PSI Zone --PSI Shutoff Valve 2 _ Tight Check _ Tight _ Leaked #1 _ Leaked --PSI □ □ BACKFLOW PREVENTION DEVICE TEST & MAINTENANCE REPORT Water Service Contact Owner/Management Contact Existing:_________New:__________Replacement Use - Type - Reduced Pressure:_______Double Check:_______Pressure VB:______Spill Resistant Date Installed:___________Last Inspection /Test:_____________Mainline Device Mechanical Test: Passed Failed If the Mechanical Test fails, the Water Purveyor/Authority must be notified immediately and repairs made as soon as possible. Explain Failures/Repairs in Detail: Alarm Company/Fire Department Notification: Turn Off Date: Time: Turn On Date: Time: Technician certifies this device has been tested in accordance with Tester Name:________________Certification Tester Test Re-Cert Owner or Agent Signature indicates Verification by Signer that Isolation Valves are in the Open Position after test. Must retain a copy of this report for a minimum of three years.