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Guidelines for City of Brighton List of Approved Certified Backflow Assembly Testers Thank you for your interest in being placed on the City of Brighton’s list of Approved Certified Backflow Assembly Testers. The City of Brighton’s guidelines are listed below. In order for a tester to be added to and remain on our Certified Tester list the following is required: What You Must Send Us: 1. Complete Backflow Assembly Tester Application Form 2. ASSE, ABPA or ABC Tester certificate as well as a copy of the wallet card which shows the expiration date and certificate number. When your certificate is renewed we must receive a copy of the current card and new expiration date to remain on the list 3. Gauge Calibration Certification of all testing equipment showing calibration within the last (12) twelve months. 4. Fire Registration with the State of Colorado are to be provided the first of every year for those who wish to test fire devices. 5. Contractor’s License with the City of Brighton must be provided and renewed as required. You will not be reminded to send us this information. The list is revised and should your licenses not be current, you will automatically be removed from the list What You Must Do: 1. Ensure that test forms are complete, accurate, and legible. Failure to submit reports that are complete and accurate may result in rejection of all test reports, removal from the City’s list, and/or a requirement to retest the backflow assembly. 2. Submit all test forms to the City’s Backflow Program within (10) ten days of completion. 3. Provide a copy of the completed test report to the property owner and/or person in charge of premise. 4. Provide the City with copies of the above-referenced required documentation annually. You will be responsible to do this. You will not be notified by our office to update required information. 5. Be responsible for quality control and provide Brighton’s customers with accurate tests results. We Reserve the Right To: 1. Randomly check test results submitted. 2. Remove your name from the City’s list for failure to follow these guidelines. If you are removed from the list, any test reports from you, or your company, will not be accepted. 3. List your information for customers on the City website. Information will include, but is not limited to: Tester’s Name, Telephone Number, and Certification Number 4. Accept faxed/emailed copies of test reports. The City may, at its discretion, require that only originals be sent via mail or hand carried to the Backflow Office. We appreciate your cooperation in compliance with the above requests. Please keep in mind that we offer a list of certified testers to our customers to assure them a selection of competent testers. If we become aware of problems with a tester complying with any of the above, failure to test a device according to standard testing procedures, or falsifying test reports, it will be considered grounds for automatic removal from our list in the better interest of our customers and distribution system. If you have questions, please call the Backflow Prevention Program at (303) 655-2121 Page 1 of 2 ---PAGE BREAK--- BACKFLOW ASSEMBLY TESTER APPLICATION FORM Application: Please provide the following information then sign and date the form. Mail this application form with the required documentation to the address we have provided below. Please print clearly. Incomplete or illegible paperwork will not be accepted. Required Information (Please print) Business Business Mailing Address: City: State: Zip: Telephone E-mail Address: 1) Did you enclose a copy of your current Certificate(s) and wallet Card(s)? Y/N 2) Did you enclose a copy of your current Gauge Calibration Statement Y/N 3) If there is more than one tester and/or testing equipment in your company, please list all the information of your testing equipment and state who the test equipment belongs to or is used by: Test equipment: Make: _________Serial Used by: Test equipment: Make: _________Serial Used by: Test equipment: Make: _________Serial Used by: Test equipment: Make: _________Serial Used by: Test equipment: Make: _________Serial Used by: 4) Did you enclose a copy of your current State of Colorado Fire Registration? Y/N 5) Did you enclose a copy of your current Contractor’s License with the City of Brighton? Y/N 6) List and provide certificates of other qualifications related to Backflow Testing, such as confined space entry, backflow repair certification, etc. I, the undersigned, have read and agree to the City of Brighton Backflow Assembly Tester guidelines. Tester Name (print clearly) Date: Signature of Certified Tester: State Certification Return the Completed Application by Mail or in Person To: City of Brighton Utilities Department / Backflow Program 500 South 4th Ave Brighton, CO 80601 For More Information: Visit our website www.brightonco.gov; or contact the Backflow Prevention office Monday through Friday 8am to 5pm at: [PHONE REDACTED] Page 2 of 2 ---PAGE BREAK--- REQUIRED INFORMATION FOR BACKFLOW ASSEMBLY TEST REPORT FORMS Results must be reported on either our form or a form which provides for all required information. Testers may use the blank forms that are available at our Backflow Prevention Office; or visit our website. www.brightonco.gov The information required for Backflow Assembly Test Report forms submitted to the City of Brighton is listed below. Failed, illegible or incomplete test report forms will not be accepted. Customer & Property Information; 1. Service Address: address of the building or residence at which testing was performed. 2. Service Business Name: If applicable, name the business. 3. Customer Contact: Name and phone number of person to contact with questions. 4. Utility number: number can be obtained from the water bill. Backflow Device Information; 1. Indicate if the device is: New Installation, Existing or Replacement. Note: If Replacement, you must also include old assembly’s serial number. 2. Type of Assembly: Circle one of the choices or specify in ‘Other’. 3. Make of Assembly: Manufacturer’s name. 4. Model Number: Use complete model number. 5. Size: Size of assembly being tested. 6. Serial Number: Be accurate. Include alpha prefixes. 7. Use Isolated: Containment, isolation, domestic, fire, irrigation, carbonation machine, boiler, etc. 8. Describe Assembly Location: Please give the physical location of device, such as next to meter, West wall of room 102, 15 feet SW of building, etc. Test results: 1. Values are required for each check valve tested 2. Final test results if applicable 3. For Air Gap Inspections, indicate whether proper air gap separation is provided. 4. Check Passed or Failed for entire assembly. 5. Indicate if the assembly is properly installed. Note: If the assembly is not installed in accordance with the installation requirements the discrepancy must be recorded in the comments section. 6. Indicate if water service has been restored. 7. Record the meter reading on applicable devices. 8. Make comments or recommendations. Certified Tester Information; 1. All test reports must include legibly printed or typed tester’s name, certification number, test date & time, test equipment’s make/model and serial tester’s company name, and telephone number. Note: The report form must include the signature of the person performing the test.