HIGHLAND WATER DISTRICT

BACKFLOW PREVENTION ASSEMBLY TEST REPORT

RETURN NO LATER THAN

ACCOUNT #
NAME
ADDRESS

LOCATION:

ASSEMBLY:
MANUFACTURER MODEL SIZE SERIAL #

LINE PRESSURE AT TIME OF TEST: PS/LBS TYPE OF ASSEMBLY:

REDUCED PRESSURE ASSEMBLIES PRESSURE VACUUM BREAKER

DOUBLE CHECK ASSEMBLIES RELIEF AIR INLET CHECK VALVE
1ST CHECK 2ND CHECK VALVE OPENED AT
____ PSI _____ PSI
INITIAL TEST DC-CLOSED TIGHT____ CLOSED TIGHT___ OPENED AT DID NOT OPEN LEAKED
RP- _____PSID _____PSID
LEAKED _____ LEAKED _____
REPAIRS &
MATERIALS
USED
TEST AFTER DC-CLOSED TIGHT____ CLOSED TIGHT OPENED AT OPENED AT
REPAIRS RP- _____PSID _____PSID _____PSID _____PSID

AIR GAP INSPECTION: REQUIRED MINIMUM AIR GAP SEPARATION PROVIDED YES _____
NO _____

REMARKS:

THE ABOVE REPORT IS CERTIFIED TO BE TRUE:

INITIAL TEST PERFORMED BY: CERT # DATE:
REPAIRED BY: DATE:
FINAL TEST PERFORMED BY: CERT # DATE:

WATER SERVICE RESTORED: YES ______ NO _____

DOES THIS ASSEMBLY PASS: YES ______ NO _____

TESTERS SIGNATURE

CUSTOMERS SIGNATURE