2. 
4. BACKFLOW PREVENTION ASSEMLY TEST REPORT

   PER WAYNESBORO CITY CODE **** BACKFLOW ASSEMBLIES REQUIRE ANNUAL TESTING.  *****

6. Account Information
8. ACCOUNT HOLDER/OWNER NAME*
9. Property Address*
11. Account Contact*
12. Contact Phone Number*
14. Account Holder Contact Address:*

    House #, Apt/Suite, Street, State, Zip Code

15. Email*
19. Inspection Information
21. Location of Assembly*
22. What does this device serve?*
    -- Select One --DOMESTICIRRIGATIONFIRELINEBOILEROTHER
23. Type of Assembly*
    -- Select One --RPDCVAPVBDCRPDASVB
24. Size*
26. Test Type*
    -- Select One --ANNUAL TESTNEW DEVICE TESTDEVICE RETESTDEVICE REPLACEMENT
27. Inspection Date*
    Inspection Date
28. Is this assembly installed in accordance with manufacturer recommendation and/or local codes?*

    1. YES
    2. NO
30. Assembly Mfg/Make:*
31. Model:*
32. Serial No.*
34. Test Gauge MFG/Serial Number/Calibration Date*
38. Check Valve 1
39. Pressure across CV1 (PSI)*
40. CV1

    1. Closed Tight
    2. Leaked
42. Check Valve 2
43. Pressure across CV2 (PSI)*
44. CV2

    1. Closed Tight
    2. Leak
46. Relief Valve Opening Pressure ( PSI)
47. Relief Valve

    1. Opened
    2. Did not open
48. Outlet Shutoff Valve

    1. Closed
    2. Leaked
50. Static Line Pressure (PSI)
51. Buffer Zone (PSI)
53. Repair or Maintenance
54. Pass/Fail*

    1. PASS
    2. FAIL
55. Has Test Tag been installed on assembly?

    1. YES
    2. NO
59. Firm Name
60. Firm Address*
61. Phone Number*
63. Certified Tester Name*
64. Certified Tester Number*
65. Expiration Date
67. Additional Comments
    Please Type Additional Comments Here.
69. Submittal Date*
    Submittal Date

    Submittal Date
70. Signature of Tester

    By Entering First and Last Name, You agree that the information you have provided is accurate to your knowledge.

Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field