Backflow Prevention Assembly Test Report

FAILED, ILLEGIBLE OR INCOMPLETE REPORTS WILL NOT BE ACCEPTED

6670 Lockville Rd., Carroll, OH 43112
Phone: (740) 652-7129
Email: askutilities@co.fairfield.oh.us

1. Customer & Property Information

Property Address

Zip Code

Business Name

Contact Person

Fax Number

2. Device Information

Installation Status

New Existing / Replace

Old Assembly Serial # (if replacement)

Type

AirGap RP DC PVB

Make of Assembly

Model

Size

Serial Number

What hazard is being isolated? (i.e. irrigation, complete)

Describe location of assembly

3. Test Results

TEST TYPE	Double Check (DC)		Reduced Pressure (RP)		Pressure Vacuum (PVB)
Initial Test	1st Chk:	2nd Chk:	1st Chk:	Relief Op:	Air Inlet:	Check Vlv:
Initial Results	P F	P F	P F	P F	P F	P F
Additional Info	Line Pressure:		2nd Chk (RP) held:		Outlet Valve: Pass Fail
Final Test

REQUIRED AIR GAP PROVIDED?

YES NO

MEETS PIPING REQUIREMENTS?

YES NO

FINAL ASSEMBLY RESULT: PASSED FAILED

* REPAIRS MUST BE COMPLETED WITHIN 10 DAYS *

4. Certified Tester Information

I CERTIFY THAT ALL INFORMATION ON THIS REPORT IS TRUE AND ACCURATE

TESTER PRINTED NAME

OHIO CERT #

TESTER PHONE

TESTER COMPANY NAME

GAUGE MAKE/MODEL & SN# / CALIB DATE

TESTER SIGNATURE

TEST DATE