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					                BACKFLOW PREVENTION ASSEMBLY TEST REPORT
                                                  Please return report to:
                                                  Utility Lines Division
                                                  424 Saint Andrew Street
                                                  Petersburg Va. 23804
                                                  Attn: Steve Daniel
                                                  PH # 804 -733-2407
                                                  FAX # 804 733 2342


INSTALL ID: ________________         ACCOUNT #:

NAME OF PREMISE:                                                                                    Commercial o     Residential o

SERVICE ADDRESS:                                                                  CITY:                         ZIP:_________________

CONTACT PERSON:                                           PHONE:                                    FAX:

LOCATION OF ASSEMBLY

DOWNSTREAM PROCESS:                                                       DCVA o        RPBA o      PVBA o       OTHER:

NEW INSTALLATION       o EXISTING o REPLACEMENT o OLD ASSEMBLY SERIAL NUMBER:

MAKE OF ASSEMBLY:                             MODEL:                           SERIAL NO.:                        SIZE:

   INITIAL          DCVA/RPBA                   DCVA/RPBA                          RPBA                          PVBA
    TEST          CHECK VALVE NO.1            CHECK VALVE NO.2                                                 AIR INLET
                                                                             OPENED AT           PSID
                              o                           o                                           OPENED AT            PSID      DID
 PASSED o         LEAKED                      LEAKED
                  CLOSED TIGHT o              CLOSED TIGHT o                 #1 CHECK            PSID OPEN                   o
 FAILEDo                        PSID                        PSID
                                                                             AIR GAP OK?________
                  CLEAN REPLACE     PART      CLEAN REPLACE     PART         CLEAN REPLACE   PART           CHECK VALVE
                  o       o                   o       o                      o     o                     HELD AT        PSID
  PARTS           o       o                   o       o                      o     o                     LEAKED         o
    &             o       o                   o       o                      o     o
 REPAIRS          o       o                   o       o                      o     o                     CLEANED             o
                                                                                                         REPAIRED            o

    TEST          CLOSED TIGHT       o        CLOSED TIGHT       o           OPENED AT           PSID AIR INLET              PSID
   AFTER                             PSID                        PSID        #1 CHECK            PSID
   REPAIRS                                                                                            CHK VALVE              PSID

AIR GAP INSPECTION: Required minimum air gap separation provided? Yes o   No o      Detector Meter Reading

REMARKS:

                                                                                                        LINE PRESSURE

TESTER’S SIGNATURE                                                     CERT. NO.                        DATE TESTED

TESTER’S NAME PRINTED                                                  TESTERS PHONE # (            )

REPAIRED BY                                                            CERT. NO.                        DATE

FINAL TEST BY                                                          CERT. NO.                        DATE

GAGE CALIBRATION DATE ______/______/______                    WATER SERVICE RESTORED                 YES   o NO o

				
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