Universal CO Test Form (protected)

City of Golden
CCC Program
1445 10th Street
Golden CO 80401
Ph: 303-384-8178 Fax: 303-384-8161
Assembly Serial #
Test Date/Time
Gauge Serial #
►District Required Info
Tester Certification #
Date Certification Expires
[email protected]
Assembly Test Results
Backflow Prevention Assembly Test & Maintenance Report
…
Pass
Test #:
…Fail
Account
Owner □ Manager □ Contractor □
Company Name/ Title:
Mailing Address:
Assembly
Water District/ Authority:
Facility Name:
Service Address:
Mailing Address:
OMC
(Please Print)
Make:
Type: … RPZ
Date Installed:
Contact Person:
Contact Phone # :
Other:
Contact Person:
Contact Phone # :
Model:
… PVB
… Air Gap
… SVB
Location on Property:
Orientation
(Only if Applicable - Include Previous Serial#)
□ Replacement Assembly
Inlet:
Outlet:
□ ↑ Vertical Up ↑ □
□ New Installation
□ ↓ Vertical Down ↓ □
□ Stolen
□ → Horizontal → □
Previous Assembly Serial #
Line PSI:
… DC
(Ck#2: RPZ, DC)
Repaired:
Initial Test Results
Tightness Differential Ck#1□ Ck#2□ RV□
□ Leak
Ck#1
□ Tight
disc□ spring□ seat□ other:
□ Leak
Ck#2
□ Tight
disc□ spring□ seat□ other:
Relief Valve
RV
(RV: RPZ)
diaphram □
Check Valve #1
(Ck#1: RPZ,DC,PVB,SVB)
Check Valve #2
Testing & Maintenance
Account:
…AVB
Size:
…Other
Service
□ Domestic
□ Fire
□ Irrigation
□ Other
Protection
□ Containment
□ Isolation
□ Containment
By Isolation
Cleaned:
Ck#1□ Ck#2□ RV□
Re-Test Results
Tightness Differential
□ Leak
□ Tight
□ Leak
□ Tight
seat□ other:
Buffer
Repaired:
Cleaned:
(RPZ)
Air Inlet □
Air Inlet□
Air Inlet
Air Inlet
(Air Inlet: PVB,SVB)
poppet □
bonnet□ other:
SOV #1 Open Upon Arrival:□ Open Upon Departure: □
Backpressure Exists?
SOV #2 Open Upon Arrival □ Open Upon Departure: □
Cause:
Shutoff Valve #1
□ Leak □ Tight
Shutoff Valve #2
□ Leak □ Tight
Assembly Concerns: Test Procedure:
(only if applicable)
Incorrect Installation?
Incorrect Use ?
/
/
□ ABPA □ ASSE □
□
Turn On Date:
Turn On Time:
/
/
:
Notice
:
□ No □
Comments:
Alarm Company/Fire Department Notified:
Person Notified:
Turn Off Date/Time:
Kit
Turn Off Date:
Turn Off Time:
Yes
Test Gauge Make:
Contacted By:
Turn On Date/Time:
Model:
Last Calibration Date:
/
/
Tester
I hereby certify that the Isolation / Shutoff Valves (SOV#1 and SOV #2) have been returned to the position in which they were found and that the 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.
(Please Print)
(Please Print)
Testing Company: _____________________________ Phone #: _____________
Customer Name: ________________________
Tester Name:
(Please Print)
(Tester)
(Customer)
Signature:
Signature:
Phone #:______________