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    Orange County Utilities Water Division Backflow Prevent Er Field Test Report

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    This document is a backflow preventer field test report containing information about a backflow prevention assembly test. It includes details like the customer and service address, assembly details like manufacturer and model, test results indicating if it passed or failed, and the tester's contact information. If repairs were needed after a failed test, they are documented. Test reports must be kept on file for 10 years according to local regulations.

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    Orange County Utilities Water Division Backflow Prevent Er Field Test Report

    Uploaded by

    Ro
    47 views1 page
    This document is a backflow preventer field test report containing information about a backflow prevention assembly test. It includes details like the customer and service address, assembly details like manufacturer and model, test results indicating if it passed or failed, and the tester's contact information. If repairs were needed after a failed test, they are documented. Test reports must be kept on file for 10 years according to local regulations.

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    Backflow_Test_Form

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    This document is a backflow preventer field test report containing information about a backflow prevention assembly test. It includes details like the customer and service address, assembly details like manufacturer and model, test results indicating if it passed or failed, and the tester's contact information. If repairs were needed after a failed test, they are documented. Test reports must be kept on file for 10 years according to local regulations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    47 views1 page

    Orange County Utilities Water Division Backflow Prevent Er Field Test Report

    Uploaded by

    Ro
    This document is a backflow preventer field test report containing information about a backflow prevention assembly test. It includes details like the customer and service address, assembly details like manufacturer and model, test results indicating if it passed or failed, and the tester's contact information. If repairs were needed after a failed test, they are documented. Test reports must be kept on file for 10 years according to local regulations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Orange County Utilities Water Division

    BACKFLOW PREVENTER FIELD TEST REPORT


    PLEASE PRINT or TYPE

    Customer Name: ____________________________________________________________________________


    Service Address: _________________________________ City: ____________ State: ______ Zip: __________
    Account #: _____________________ Meter #:______________________ Reading: ______________________
    (required)

    Company Name/Contractor: ___________________________________________________________________


    Mailing Address: _______________________________ City: ________________ State: ______ Zip: _________
    Phone: ____________________ Fax:____________________ Email:__________________________________
    Gauge Mfr.: ____________________ Serial #: ________________________ Calibration Date:_______________
    Check Areas
    Point of Use: Irrigation Fire Domestic Reclaimed Service
    Assembly: Reduced Pressure Double Check Pressure Vacuum Breaker
    Device: Existing New

    Mfr.: ________________________ Model #: ___________________ Size: ____________ Serial #: _________________

    Device Location: ______________________________________________________________________________________

    ASSEMBLY TEST
    Check Valve (CV) #1 CV # 2 Relief Valve PVB Shutoff Valves (SV)
    Assembly Test Closed Closed Air Inlet Opened at SV # 1
    Tight Tight Opened at Closure
    Annual ____________ PSID
    Leaked Leaked __________PSID
    Did Not Open Leaked
    Retest
    Did Not Open
    PSID Across PSID Across SV # 2
    Check Valve PSID CV Closed
    Check Valve Exercised Closure
    at __________
    ______________ ______________
    Leaked Leaked

    Repairs Cleaned Cleaned Cleaned Cleaned Cleaned

    Replaced Replaced Replaced Replaced Replaced

    Repaired Repaired Repaired Repaired Repaired

    This operational test Passed or Failed . I certify this test to be a true operational representation

    of the above assembly at the time and date of this test. Date: _________________ Time: __________________

    Comments:

    Tester's Name (print): ______________________________ Tester's Signature: __________________________

    Certification #:________________ Issue Date:______________ OCU Tester Registration #:_________________

    Test Report must be maintained for a period of 10 years per DEP-62-550.720(3)

    Provide Test Report To: Owner of the assembly and


    Orange County Utilities Water Division, c/o Cross Connection Control Program
    8100 Presidents Drive, Suite C, Orlando, Florida 32809
    Phone: 407-836-6970, Fax: 407-836-6830, Email: Water.Backflow@ocfl.net

    Para más información, por favor llame al Departamento de Servicios Públicos del Condado
    de Orange y pida hablar con un representante en español. El número de teléfono es 407-836-6970.

    Website: www.ocfl.net/CrossConnection Revised 11/17

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