City of Perrysburg, Division of Water 211 East Boundary Perrysburg, Ohio 419.872.8050 Backflow Prevention Assembly – Test Report Form Facility Name: _____________________________________________ Address: __________________________________________________ Tester: Check One New Installation Annual Test: Year _____ Device Information Type: (circle one) RPZ DC PVB Air Gap Manufacturer/Model: _______________________ Size: ______ Serial: ______________________ What hazard is being protected? (i.e.) boiler, irrigation, complete building) ____________________ ________________________________________________________________________________ Describe where assembly is located: __________________________________________________ Reduced Pressure Principle Assembly Pressure Vacuum Breaker Double Check Valve Assembly 1st Check □ DC-Closed Tight Initial Test Air Inlet 2nd Check RP-____________psid Leaked………………... Relief Valve □ Leaked…………□ Closed Tight….. □ Check Valve Opened at: Opened at: ____________psid ____________psid Did not open…... □ ____________psid Leaked………. □ Repairs and Material Used DC-Closed Tight ….. Final Test □ RP-____________psid Closed Tight….. □ Opened at: Opened at: ____________psid ____________psid ____________psid Remarks: (Describe deficiencies: bypasses, outlets before the device, connections between the device and the point of entry, missing or inadequate air gaps, etc…) Certified Tester Information I hereby certify this report to be true Tester Name (print): _________________________ Cert. No.: ______________________ Business Name: ______________________________ Phone: ________________________ Testers Signature: _____________________________ Date: __________________________ Property Owner Information Certification that test was performed. Owner’s/Agent’s Name: _________________________________ Title: __________________________ Owner’s/Agent’s Signature: ______________________________ Phone: _________________________ Notify owner and Division of Water (419-872-8050) immediately if device fails test and repairs can not be made that day.
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