Time of Test: #2 Gate or Ball (Circle One) (Mark One) The purpose of form TCEQ-20700 Backflow Prevention Assembly Test and Maintenance Report (T&M Form) is to document the results of testing a backflow prevention assembly. ANNUAL TEST AND MAINTENANCE REPORT FOR ; BACKFLOW PREVENTION ASSEMBLIES . If you have any questions, please contact KC Water Backflow Division at 816-513-4795 or email at backflow@kcmo.org. BACKFLOW PREVENTER ASSEMBLY REPAIR INFORMATION & RE-TEST REPORT FORM (Print Clearly) Please Note: Prior to repair contact the local Plumbing Dept. E-Notify. MAPAC-006-2009: Premises isolation backflow preventer installation up to 1 size with thermal expansion relief valve. Get the Scdhec Backflow Test Report Form . P://OPS/Xconn/Repair & Re-test Form #10 rev 2018-03 The Main menu. DEPT. 1/15/2010 rev. Completed Test and/or Rebuild Report . 2020 Water Quality Report; 2020 Water Quality Reports (Johnston) 2020 Water Quality Report (Whipple) 2019 Financial Report; About Us. That test, conducted by the generic manufacturer in a handful of healthy individuals, is designed to cialis ganeric confirm that the Mexican pharmacy you're dealing with is licensed, as many are not. MGMT. Backflow Prevention Device Test Report Division Contact Info Steve Miller or Lindley Paynter Office 919-249-3427 Fax 919-367-7280 For more information on Fairfields backflow program, including access to blank test report forms Email Test Reports To: backflow@chesterfield.gov. Austin, TX 78744. BACKFLOW PREVENTION. Backflow Prevention Assembly Test Report You may fax this report to (913) 573-9690 or email to backflow@bpu.com. Be advised that the Rosenberg and Galveston have some form of payment required to process their backflow test reports. Report on Test and Maintenance of Containment Backflow Prevention Assembly (FORM GEN215B) Use a separate form for each particular assembly Indicate Initial Test or Annual Test The following numbers refer to the enclosed form. BACKFLOW PREVENTION ASSEMBLY TEST REPORT CITY OF BELLEVUE Water Quality Box 90012 Bellevue, WA 98009 EMAILTO: Backflow@Bellevuewa.gov (425) 452-7840 FAX (425) 452-7116 NOTE: all new backflow assemblies installed must be tested prior to plumbing final, Microsoft Word - 2015 TestReport Form All Backflow Testers must register with the Public Health and Environmental Quality Department annually to test in the City of Grand Prairie. Contact us at 415.945.1488 or Backflow@MarinWater.org with any questions. YELLOW The information in this report is true, complete, and accurate. A backflow test form is a report created by a plumber to determine the status of the plumbing at a construction site. A signed and dated original must be submitted to the public water supplier for recordkeeping *purposes: 2. Receive an automatic email with an attached pdf of the report to send to your customer or print a hard copy from a mobile printer (cost about 1634 HENRICO . BAT Signature (initial test) Cert. A backflow prevention device or assembly must meet American Society of Sanitary Engineering standards (ASSE). Commercial and residential customers are responsible for submitting annual backflow test results to the Town. MAPAC-008-2010: Premises isolation backflow preventer installation up to 2 size with floor mounted expansion tank. ASSE International . Preventing Backflow. The following form must be completed for each assembly tested. If not an annual Test, please select one of the following: New Assembly Remove 419-898-5028. Cross Connection Control. BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT The following form must be completed for each assembly tested. Also, you can also get the qualified template free of charge and complete the form right away at CocoSign. Reduced Pressure Principle Assembly Double Check Valve Assembly Check Valve #1 Check Valve #2 Relief Valve PVB/SVB Initial Leaked Leaked AIR INLET KCKBPU Backflow Test Form Click Here for the requirements to register with the City of Houston as a backflow prevention assembly tester. 2 Leavenworth, Washington, 98826 Directions. # Describe minor installation changes. Registration form and required documents may be may 13th, 2018 - backflow assembly test report form backflow prevention assemblies in order that water service will not backflow prevention certification workshop booklet' 'Texas Commission on Environmental Quality Specialties: Backflow testing, Maintenance, Repairs, and Replacement For Backflow Emergency Call Me Anytime. You may fax this report to (913) 573-9636or email to backflow@bpu.com Please ONLY submit PASSING test results. I certify that this report is accurate, and I have used WAC 246 Backflow Assembly Test Inspection Form - Page 1 Form of 2 / 1799702 . 06/21/2011 gfb W:\DATA\FORMSARCHIVE\WP\CROSS CONNECTION\BACKFLOW TEST REPORT FORM.DOC. test and maintennce report rp clean. Court Order and Opinion - 1/21/22. Backflow Prevention Assembly Test Report You may fax this report to (913) 573-9690 or email to backflow@bpu.com. Denver Water Backflow Assembly Test & Maintenance Report (please print CLEARLY with BLOCK LETTERING) Testing Company: Submit by e-mail (preferred) to BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT. Currently, we only accept hardcopy test reports by mail. If you use the PDF form, submit test and maintenance results by one of the following methods: Scan and email. Backflow Prevention Device Repair Information & Re-test Report Form. Test kit number Certification date of calibration / / Testers name License number Phone Testers signature Contractors business name or stamp Date / You must forward the completed form within 7 days to - I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB. Test Before RepairS Leaked Closed Tight Diff Press Repairs and New Materials Electric City Utilities 314 Tribble Street Anderson, SC 29625 (864) 231-5230 Fax (864) 332-5343 twideman@cityofandersonsc.com BACKFLOW DEVICE TEST REPORT FORM DATE: Meter Number: Meter Reading: Model Number: Size. 275 Merton St. Toronto, ON M4S 1A7. Reduced Pressure Principle Assembly Double Check Valve Assembly BPU Form Notification # Manufacturer; Notification # Search. Title: Microsoft Word - Backflow Prevention Assembly Test Report.doc Author: RobJ Created Date: 3/3/2009 10:59:44 AM must be filling out. Annual Reports; Board of Directors; Did You Know? STATE FORM 55788, BACKFLOW DEVICE TEST 327 IAC 8-10-9(b) TYPE OR PRINT ALL ENTRIES. PREVENTION ASSEMBLY TEST REPORT RETURN TO: Water Division . The construction site will have several pipes that carry water, waste, or both. Please return the completed form to: Henrico County Department of Public Utilities Attn: Water Quality Engineer 10401 Woodman Rd Glen Allen, VA 23060 . backflow test status [ ] pass [ ] fail . City of Leavenworth. 1. A signed and dated original must be submitted to the FAX : 253-502-8721. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB. Click here for a copy of the COH Backflow Preventer Test Report and Maintenance Form. DC Water's Compliance Program promotes and enforces backflow prevention to reduce health risks posed by cross-connections. Water and Sewer Rates & Utility Payment. Physical Address: 700 Hwy. FAQs. A cross-connection is a Important Notice. Fill in forms will accept only a limited amount of information in each individual box. 2. the . Backflow Forms. PWS ID# 0610023. Backflow Test Instructions and Report Form; Backflow-Test-Report-and-Instructions Download. # 0570010 Casimiro Kasi Ruiz 972-205-3214 Denise Wilson 972-205-3205 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE Town of Flower Mound. Also I am an irrigation specialist. # Sign and date form and indicate NYSDOH (or local health department/water supplier). Due to recent changes in our team here we will no longer be preforming the annual backflow inspections, test, or repairs as needed. Mail: Cross All completed Cross Connection Control/Water Protection forms (excluding Test and Maintenance Reports) should be submitted via email at awcrossconnection@austintexas.gov or mailed to: Austin Water, Special Services Division. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test Reduced Pressure Principle The form Registration form and required documents may be faxed at 972-237-8228 and payments over the phone at 972-237-8055 or in person at City Hall, 300 W. Main St., 2nd Floor, Grand Prairie, TX 75050. All backflow test results must be submitted through the Online Backflow Test Entry System. The Cross Connection Program is responsible for ensuring potable water provided by the City remains safe throughout the water distribution system and is protected from backflow events. (an undesirable reversal of potentially contaminated water from a customer to the Citys system.). Ahmad Cade, Backflow Manager. Author: dodiepohl Created Date: After testing is complete, your certified backflow tester will put your sticker labels on your report and mail the 2121 Cross Timbers Rd. Repairs, maintenance, Replacement on sprinkler and valves. Bac-Flo Unlimited offers the most comprehensive backflow training courses with free troubleshooting assistance after 24 or 40 hour course completion. All new testers must submit this application to be added to the approved Marin Water Testers List. Backflow Test Report Form. Test backflow prevention assemblies using a certified tester: After initial installation; Annually thereafter; Use this test report form for all new assemblies; Submit completed test reports to WaterOne; WaterOne staff will review any existing or proposed connections to the public water supply system for hazards which may require a BPA. Click here for a list of test gauge calibration facilities. Tacoma, WA 98411-0007 . Backflow Prevention Program. Replacing Model, Make, Serial : New : Part 1: Location & People Information ; Site Address: Owner Name: Day Phone: You may fax this report to (913) 573-9636or email to backflow@bpu.com Please ONLY submit PASSING test results. Owner of Property _____ Address _____ This form shall be used for backflow devices If device fails the initial test, this form should indicate the failing test, the repensure new device will meet all current standards set by SCDHEC Submit test reports. PWS ID# 0610023. Department o; f ; Environmental Services -PLEASE FILL OUT COMPLETELY-Office Address: PO THIS FORM MUST BE COMPLETED FOR EACH ASSEMBLY TESTED. Email: The Cities of Sugar Land, Beaumont, League City, and Willis process their test reports through BSI Online. 2121 Cross Timbers Rd. This course will cover the basic information needed to understand the concepts and fundamentals of cross connection control. For questions or to report problems: 419-898-5028. Initial Test Test After Repair. Phone: 651-714-3720 Fax: 651-714-3721. What Is Backflow Testing?Function. The function of a backflow prevention device is to keep dirty water from pools, storm drains and other external water sources from flowing backward into clean, uncontaminated water or Types. Backflow prevention devices or strategies are required in most local building and plumbing codes. Prevention and Testing. 4. Backflow Assembly Test Report. All forms are required to receive a plumbing inspection final Backflow Test Form 07-26-17. Street West, Apple Valley, MN 55124 . BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT. 1 Backflow Testing Process. Once the formalities have been done, the actual test can begin. There are two main purposes of the test, to see if backflow is present and to determine the issue that is causing it, so that it can be fixed. The testing process involves using valves on the backflow testing device, known as gate and relief valves. 10/22/90 rev. The test form must be completed and signed by an individual certified in backflow Testers and customers can send any documents regarding backflow questions or issues to ATLbackflowoffice@atlantaga.gov. Backflow Assembly Test Inspection Form - Page 1 Form of 2 / 1799702 . Double Check Backflow Prevention Assembly (DC) ASSE Standard #1015 Field Test Report . THE ABOVE REPORT IS CERTIFIED TO BE TRUE: Date: Other/Notes: Held at PSID Opened at PSID Closed Tight Closed Tight Hinge Pin Hinge Pin O-Ring(s) Diaphragm Module Module Module Please ONLY submit PASSING test results. At least once every twelve (12) months, each backflow preventer must be tested by an Ohio certified tester, and repaired if needed, to confirm is functioninitg properly. The Woodlands processes their forms online through VEPOLLC.com. 9/27/2016 university of florida treeo center test and maintenance report customer: street address: mailing address: location of Water Protection Officer 972-874-6374. For instructions on how to submit a backflow test/inspection, see On-Line Test Submittal User Guide or backflow test/inspection video. After completion, submit copies of test reports to the supplier of Initial Test Test After Repair. or Fire Dept. Phone: 404-546-3239. Contact Information. Phone: (509) 548-5275 Fax: (509) 548-6429 After review of your documents, we will process your application and schedule a hands-on Print Name Signature Final Test By: Company Tester Ph. All new testers must submit this application to be added to the approved Marin Water Testers List. Try for free. Search form. View this guidline to know more about Backflow Test Forms Printable. 3907 South Industrial Dr, Suite 100. E-mail: publicworks@woodburymn.gov. Water Protection Officer 972-874-6374. test gauge used: make/model: s/n: calibration date: remarks: the above test is certified to be true at the time of testing . Your backflow preventer should be tested every 12 months. The result of each test needs to be submitted to the relevant water authorities. What Does Testing the Backflow Device Involve? An accredited mechanical plumber performs backflow testing that includes opening and closing various valves to check for irregularities. It will prepare students for training in testing backflow prevention devices or conducting cross-connection surveys. Fax: 404-235-2054. acade@atlantaga.gov. Reduced Pressure Principle Assembly Double Check Valve Assembly BACKFLOW TEST REPORT FORM. A signed and dated original must be submitted to the public water supplier for recordkeeping * purposes: TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC 290.46(B)] USE ONLY MANUFACTURER'S REPLACEMENT PARTS A SIGNED AND DATED ORIGINAL REPORT SUBMITTED TO: 1. Fax: (813) 635-1612. # Registration No Registration Date: Expiration Date: THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE Atlanta, GA 30303. The backflow prevention device or assembly must be installed when required to prevent cross-connections. Coordinator at the address or fax number shown at the top of this page no later than 30 days after completion of the test. Contact (937) 781-2631 to become an approved tester. 72 Marrietta Street. 3. backflow prevention assembly test report (for field use only) install/tester id: permit # account #: (acc # not required) name of premises: commercial residential service address: city: zip: contact Existing Model, Make, Serial . Backflow Assembly Test Form. BACKFLOW ASSEMBLY TEST INSPECTION REPORT . Get Backflow Test Report Pdf Get form. Test Firm Name _____Test Firm Address_____ Most recent gauge calibration date_____ Note: All assemblies should be tagged indicating test firm address, test date, tester name and certification number For any questions or comments contact DC Water at 202-364-3144 compliance@dcwater.com Test Results PO BOX 11007 . Telephone: 416-394-8888 (Voicemail Only) Email: backflow@toronto.ca. The information in this report is true, complete, and accurate. AS2845 requires test equipment used for field testing backflow prevention devices shall be annually calibrated by a registered laboratory. I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. Existing Model, Make, Serial . We apologize for any inconvenience this may bring. Search field . cts firm name: tester name: firm address: city tester #: test date: firm phone #: tester signature: *test records must be They pointed specifically to external penile prostheses as one form cialis prescriptions of treatment that has no scientific backing. 5th Floor. BACKFLOW ASSEMBLY TEST REPORT Name: Address: Mailing Address: Location of Device: Manufacturer: Model of Device: Serial Number: Size of Device: Type of Device: Check Valve No. Title: Microsoft Word - Backflow Prevention Assembly Test Report.doc Author: RobJ Created Date: 3/3/2009 10:59:44 AM Date: Account Name/Business Name: Account Address: Account Number: Meter Number: Device Name: Model Number: Serial Number: Size: Device All Backflow Testers must register with the Public Health and Environmental Quality Department annually to test in the City of Grand Prairie. Also, the backflow prevention device or assembly must be accessible for inspection and servicing. 10340 W State Route 2, Oak Harbor OH 43449. We've Backflow Prevention Device Test Report Hampton Roads Area Name of Premises: Service Address: Use and location of Device: Device: Certification: I have made the above test and hereby certify that this Backflow Prevention Device performs satisfactorily and meets all Federal, state and local codes and regulations as required. Testers must be certified through the Ohio Department of Commerce and approved by Montgomery County Environmental Services to use the online system. For each physical address the following is required: backflow test report, copy of testers backflow license, copy of testers plumbing license and test certification of testing instrument used. Show details. Fax to: 952-953-2515 Attention: Inspections : ail to: Building Inspections,M 7100 147. th. PERMITTED ASSEMBLIES BACKFLOW PREVENTION I Also do pressure reducing valve Adjustments, Repairs, Replacements, Installation, and home pressure test. BACKFLOW DEVICE TEST REPORT FORM. Tips on how to fill out the Get And Sign Backflow Test Form - Dcwsanet on the web:To begin the document, use the Fill & Sign Online button or tick the preview image of the blank.The advanced tools of the editor will lead you through the editable PDF template.Enter your official contact and identification details.Apply a check mark to indicate the choice wherever necessary.More items Mailing Address: P.O. BACKFLOW ASSEMBLY TEST INSPECTION REPORT . After review of your documents, we will process your application and schedule a hands-on demonstration held bi-annually in April and October. Please ONLY submit PASSING test results. Backflow Device Test Witnessed by.