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Water District /Authority: Service Address: Mailing Address: Company Name/Title: Mailing Address: Make: Size: Inlet: Outlet: Assembly Serial Test Date/Time: Gauge Serial Cleaned: Repaired: Re-test Results Protection type company name here previous device serial # District Required Info: Tester Certification Backflow Prevention Device Test & Maintenance Report Date Certification Expries: Assembly Test Results: (please print and submit completed copy within 10 days of the test) Facility Name: Account Contact Phone: Contact Person: Account: OMC Contact Person: Contact Phone: Assembly Model: Type: Orientation Service Date Installed: Location on Property: Line PSI: Initial Test Results: Owner Manager Contractor Other PASS FAIL RPZ DC PVB SVB Air Gap AVB Other Device Horizontal Vertical Down Vertical Up Other: Irrigation Fire Domestic Containment by Isolation Isolation Containment Stolen New Installation Replacement Device Leak Ck#1 Tight Leak Tight Ck#2 RV Ck#1 Ck#2 RV Leak Tight Leak Tight Air Inlet Air Inlet seat other: spring disc seat other: spring disc seat other: Diaphragm bonnet other: poppet Tight Leak Tight Leak YES NO Open Upon Arrival Open Upon Arrival Open At Departure ASSE ABPA Incorrect Installation Incorrect Use Open At Departure SOV SOV Cause Assembly Concerns: (only if applicable) Turn off date: Turn on date: Turn off time: Turn on time: Alarm Company/Fire Department Notified Fire suppression contractor certification # Person Notified: Contacted by: Turn off date/time: Turn on date/time: Test Kit Make: Model: Last Calibration Date: (please print) (please print) Testing Company: Phone Customer Name: Phone (please print) Tester Name: Tester Signature: Customer Signature: Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety. Backpressure exists? Air Inlet Air inlet, PVB, SVB Check Valve #1 RPZ, DC, PVB, SVB Check Valve #2 RPZ, DC RV Shutoff Valve #1 Shutoff Valve #2 Air Inlet RPZ Cleaned: Repaired: Relief Valve RV, RPZ Buffer Cleaned: Repaired: Ck#1 Re test Results Tightness Differential Testing & Maintenance Test Procedure: Line PSI: adf Initial Test Results: Tightness Differential Comments: Ck#2 Notice Kit Tester I hereby certify that the isolation/Shutoff Valves (SOV #1 and SOV have been returned to the position in which they were found and that the last test was done according to the procedure shown above required by the Water District/Authority shown above) and the test readings are true and accurate to the best of my ability. Owner Manager Contractor Other PASS FAIL RPZ DC PVB SVB Air Gap AVB Other Device Horizontal Vertical Down Vertical Up Other: Irrigation Fire Domestic Containment by Isolation Isolation Containment Stolen New Installation Replacement Device Leak Ck#1 Tight Leak Tight Ck#2 RV Ck#1 Ck#2 RV Leak Tight Leak Tight Air Inlet Air Inlet seat other: spring disc seat other: spring disc seat other: Diaphragm bonnet other: poppet Tight Leak Tight Leak YES NO Open Upon Arrival Open Upon Arrival Open At Departure ASSE ABPA Incorrect Installation Incorrect Use Open At Departure Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety. Owner Manager Contractor Other PASS FAIL RPZ DC PVB SVB Air Gap AVB Other Device Horizontal Vertical Down Vertical Up Other: Irrigation Fire Domestic Containment by Isolation Isolation Containment Stolen New Installation Replacement Device Leak Ck#1 Tight Leak Tight Ck#2 RV Ck#1 Ck#2 RV Leak Tight Leak Tight Air Inlet Air Inlet seat other: spring disc seat other: spring disc seat other: Diaphragm bonnet other: poppet Tight Leak Tight Leak YES NO Open Upon Arrival Open Upon Arrival Open At Departure ASSE ABPA Incorrect Installation Incorrect Use Open At Departure