HomeMy WebLinkAboutBackflow Preventer TestAssembly Serial #
Test Date / Time
7026 S Tucson Wy Tester Certification #
Centennial CO 80112
Phone: 303-792-0022 Assembly Test Results Pass *Fail
Fax: 303-792-9049
Water Supplier:District:Meter #:
Facility Address:City:ST:Zip:
Contact Person:Phone:
Make:Model:
Type:RP DC PVB Air Gap
Size:Date Installed:Inlet Outlet
New Existing
Previous Assembly #:
Location:
Approved:Y N
Line
PSI:
Leak Leak
Tight Tight
Leak Leak
Tight Tight
Shutoff Valve #1:Tight Leaking Replaced Shutoff Valve #2:Tight Leaking Replaced
Backpressure:Yes No Test Procedure: ABPA:ASSE:
Comments:
Alarm Company/Fire Department:DFS Certification #:
Person Notified:Contacted By:
Turn Off Date/Time:Turn On Date/Time:
Test Kit Make:Model:
Serial #:Last Calibration Date:
Testing Company:
Tester Name:Phone:
Signature:Certificate Expiration Date:
Under Suspension - Process Immediately
Denver Water Backflow Assembly Test & Maintenance Report (please print with BLOCK LETTERING)
Type of Use Protection Orientation
Horizontal
Vertical Up
Vertical Down
Initial Test Results Repairs Re-Test Results
Tightness Differential Tightness Differential
Check Valve #1
(RP, DC, PVB)
Check Valve #2
(RP, DC)
Relief Valve
(RP)
Buffer
(RP)
Air Inlet
(PVB)
Testing Company: Submit by e-mail (preferred) to CrossConnectionControl@denverwater.org,
type "Backflow Test Reports" in the subject line OR submit by Fax to (303) 794-8325.
*FAILED test results must be reported to Denver Water within 24 hours of failure at (303) 628-5969.