Show details. Fax: 404-235-2054. acade@atlantaga.gov. DC Water's Compliance Program promotes and enforces backflow prevention to reduce health risks posed by cross-connections. Environmental Compliance Section. Water and Sewer Rates & Utility Payment. E-Notify. 5th Floor. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB. Submit test reports. Backflow Prevention Program. backflow prevention assembly test report (for field use only) install/tester id: permit # account #: (acc # not required) name of premises: commercial residential service address: city: zip: contact STATE FORM 55788, BACKFLOW DEVICE TEST 327 IAC 8-10-9(b) TYPE OR PRINT ALL ENTRIES. For questions or to report problems: 419-898-5028. Receive an automatic email with an attached pdf of the report to send to your customer or print a hard copy from a mobile printer (cost about We've may 13th, 2018 - backflow assembly test report form backflow prevention assemblies in order that water service will not backflow prevention certification workshop booklet' 'Texas Commission on Environmental Quality After review of your documents, we will process your application and schedule a hands-on Owner Name: PO BOX 11007 . 10/22/90 rev. Phone: (509) 548-5275 Fax: (509) 548-6429 backflow test status [ ] pass [ ] fail . Preventing Backflow. Title: Microsoft Word - Backflow Prevention Assembly Test Report.doc Author: RobJ Created Date: 3/3/2009 10:59:44 AM PWS ID# 0610023. Search form. The information in this report is true, complete, and accurate. A backflow test form is a report created by a plumber to determine the status of the plumbing at a construction site. THIS FORM MUST BE COMPLETED FOR EACH ASSEMBLY TESTED. Ahmad Cade, Backflow Manager. The Cities of Sugar Land, Beaumont, League City, and Willis process their test reports through BSI Online. 72 Marrietta Street. BACKFLOW TEST REPORT FORM. PERMITTED ASSEMBLIES BACKFLOW PREVENTION Date: Account Name/Business Name: Account Address: Account Number: Meter Number: Device Name: Model Number: Serial Number: Size: Device BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT The following form must be completed for each assembly tested. Notification # Manufacturer; Notification # Search. After testing is complete, your certified backflow tester will put your sticker labels on your report and mail the Fill in forms will accept only a limited amount of information in each individual box. Email: For instructions on how to submit a backflow test/inspection, see On-Line Test Submittal User Guide or backflow test/inspection video. Be advised that the Rosenberg and Galveston have some form of payment required to process their backflow test reports. The form Water Quality Section . BACKFLOW DEVICE TEST REPORT FORM. Backflow Prevention Device Repair Information & Re-test Report Form. 4. Main menu. Testers must be certified through the Ohio Department of Commerce and approved by Montgomery County Environmental Services to use the online system. If you use the PDF form, submit test and maintenance results by one of the following methods: Scan and email. 1/15/2010 rev. Backflow Forms. Phone: 404-546-3239. FAX : 253-502-8721. # 0570010 Casimiro Kasi Ruiz 972-205-3214 Denise Wilson 972-205-3205 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE Initial Test Test After Repair. This protection is achieved through the installation of backflow devices or assemblies The If not an annual Test, please select one of the following: New Assembly Remove 1634 HENRICO . The Woodlands processes their forms online through VEPOLLC.com. MAPAC-007-2010: Premises isolation backflow preventer installation up to 2size with suspended expansion tank. E-mail: publicworks@woodburymn.gov. Backflow Assembly Test Inspection Form - Page 1 Form of 2 / 1799702 . Backflow Assembly Test Inspection Form - Page 1 Form of 2 / 1799702 . BACKFLOW PREVENTION ASSEMBLY TEST REPORT CITY OF BELLEVUE Water Quality Box 90012 Bellevue, WA 98009 EMAILTO: Backflow@Bellevuewa.gov (425) 452-7840 FAX (425) 452-7116 NOTE: all new backflow assemblies installed must be tested prior to plumbing final, Microsoft Word - 2015 TestReport Form For each physical address the following is required: backflow test report, copy of testers backflow license, copy of testers plumbing license and test certification of testing instrument used. A SIGNED AND DATED ORIGINAL REPORT SUBMITTED TO: 1. Backflow Test Report Form. All Backflow Testers must register with the Public Health and Environmental Quality Department annually to test in the City of Grand Prairie. Get the Scdhec Backflow Test Report Form . Test Firm Name _____Test Firm Address_____ Most recent gauge calibration date_____ Note: All assemblies should be tagged indicating test firm address, test date, tester name and certification number For any questions or comments contact DC Water at 202-364-3144 compliance@dcwater.com Test Results I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test equipment meeting WAC 246-292-034; or I personally inspected the air gap or AVB. A backflow prevention device or assembly must meet American Society of Sanitary Engineering standards (ASSE). Backflow Assembly Test Form. Reduced Pressure Principle BACKFLOW ASSEMBLY TEST INSPECTION REPORT . Phone: 651-714-3720 Fax: 651-714-3721. Test reports must be submitted to Fairfields Water Division. Currently, we only accept hardcopy test reports by mail. They pointed specifically to external penile prostheses as one form cialis prescriptions of treatment that has no scientific backing. Also, you can also get the qualified template free of charge and complete the form right away at CocoSign. Please return the completed form to: Henrico County Department of Public Utilities Attn: Water Quality Engineer 10401 Woodman Rd Glen Allen, VA 23060 . 06/21/2011 gfb W:\DATA\FORMSARCHIVE\WP\CROSS CONNECTION\BACKFLOW TEST REPORT FORM.DOC. The purpose of form TCEQ-20700 Backflow Prevention Assembly Test and Maintenance Report (T&M Form) is to document the results of testing a backflow prevention assembly. 2121 Cross Timbers Rd. Established in 2019. certified Backflow inspector since Contact Information. Registration form and required documents may be faxed at 972-237-8228 and payments over the phone at 972-237-8055 or in person at City Hall, 300 W. Main St., 2nd Floor, Grand Prairie, TX 75050. After review of your documents, we will process your application and schedule a hands-on demonstration held bi-annually in April and October. At least once every twelve (12) months, each backflow preventer must be tested by an Ohio certified tester, and repaired if needed, to confirm is functioninitg properly. THE ABOVE REPORT IS CERTIFIED TO BE TRUE: Date: Other/Notes: Held at PSID Opened at PSID Closed Tight Closed Tight Hinge Pin Hinge Pin O-Ring(s) Diaphragm Module Module Module ASSE International . A signed and dated original must be submitted to the public water supplier for recordkeeping *purposes: or Fire Dept. 3. The Waterworks Operator Certification Rule (effective January 4, 2014) includes a section on backflow preventer inspection and field test report content ( WAC 246-292-036 ). If you have any questions, please contact KC Water Backflow Division at 816-513-4795 or email at backflow@kcmo.org. We apologize for any inconvenience this may bring. BACKFLOW PREVENTION. All new testers must submit this application to be added to the approved Marin Water Testers List. MGMT. test gauge used: make/model: s/n: calibration date: remarks: the above test is certified to be true at the time of testing . 1. Test Before RepairS Leaked Closed Tight Diff Press Repairs and New Materials Electric City Utilities 314 Tribble Street Anderson, SC 29625 (864) 231-5230 Fax (864) 332-5343 twideman@cityofandersonsc.com BACKFLOW DEVICE TEST REPORT FORM DATE: Meter Number: Meter Reading: Model Number: Size. Report on Test and Maintenance of Containment Backflow Prevention Assembly (FORM GEN215B) Use a separate form for each particular assembly Indicate Initial Test or Annual Test Owner of Property _____ Address _____ That test, conducted by the generic manufacturer in a handful of healthy individuals, is designed to cialis ganeric confirm that the Mexican pharmacy you're dealing with is licensed, as many are not. This form shall be used for backflow devices Please ONLY submit PASSING test results. Completed Test and/or Rebuild Report . The backflow prevention device or assembly must be installed when required to prevent cross-connections. BACKFLOW ASSEMBLY TEST REPORT Name: Address: Mailing Address: Location of Device: Manufacturer: Model of Device: Serial Number: Size of Device: Type of Device: Check Valve No. 1 Mailing Address: P.O. Test backflow prevention assemblies using a certified tester: After initial installation; Annually thereafter; Use this test report form for all new assemblies; Submit completed test reports to WaterOne; WaterOne staff will review any existing or proposed connections to the public water supply system for hazards which may require a BPA. All Backflow Testers must register with the Public Health and Environmental Quality Department annually to test in the City of Grand Prairie. ANNUAL TEST AND MAINTENANCE REPORT FOR ; BACKFLOW PREVENTION ASSEMBLIES . Street West, Apple Valley, MN 55124 . It will prepare students for training in testing backflow prevention devices or conducting cross-connection surveys. # Describe minor installation changes. MAPAC-008-2010: Premises isolation backflow preventer installation up to 2 size with floor mounted expansion tank. Time of Test: #2 Gate or Ball (Circle One) (Mark One) Coordinator at the address or fax number shown at the top of this page no later than 30 days after completion of the test. Create Professional backflow test reports on the spot. Annual Reports; Board of Directors; Did You Know? BACKFLOW PREVENTER ASSEMBLY REPAIR INFORMATION & RE-TEST REPORT FORM (Print Clearly) Please Note: Prior to repair contact the local Plumbing Dept. cts firm name: tester name: firm address: city tester #: test date: firm phone #: tester signature: *test records must be The Compliance Program's goals are educating the public on the importance of maintaining backflow preventers, eliminating unnecessary cross-connections, and preventing backflow incidents through inspection and regulation. BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT. Backflow Testing Process. Once the formalities have been done, the actual test can begin. There are two main purposes of the test, to see if backflow is present and to determine the issue that is causing it, so that it can be fixed. The testing process involves using valves on the backflow testing device, known as gate and relief valves. FAQs. The test form must be completed and signed by an individual certified in backflow Backflow Test Instructions and Report Form; Backflow-Test-Report-and-Instructions Download. # Registration No Registration Date: Expiration Date: THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE Town of Flower Mound. AS2845 requires test equipment used for field testing backflow prevention devices shall be annually calibrated by a registered laboratory. A signed and dated original must be submitted to the public water supplier for recordkeeping * purposes: TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC 290.46(B)] USE ONLY MANUFACTURER'S REPLACEMENT PARTS All forms are required to receive a plumbing inspection final Backflow Test Form 07-26-17. Your backflow preventer should be tested every 12 months. The result of each test needs to be submitted to the relevant water authorities. What Does Testing the Backflow Device Involve? An accredited mechanical plumber performs backflow testing that includes opening and closing various valves to check for irregularities. Existing Model, Make, Serial . Click here for a copy of the COH Backflow Preventer Test Report and Maintenance Form. Also I am an irrigation specialist. Fax: (813) 635-1612. A signed and dated original must be submitted to the YELLOW Reduced Pressure Principle Assembly Double Check Valve Assembly Check Valve #1 Check Valve #2 Relief Valve PVB/SVB Initial Leaked Leaked AIR INLET KCKBPU Backflow Test Form Search field . P://OPS/Xconn/Repair & Re-test Form #10 rev 2018-03 Water Protection Officer 972-874-6374. I Also do pressure reducing valve Adjustments, Repairs, Replacements, Installation, and home pressure test. A cross-connection is a Tips on how to fill out the Get And Sign Backflow Test Form - Dcwsanet on the web:To begin the document, use the Fill & Sign Online button or tick the preview image of the blank.The advanced tools of the editor will lead you through the editable PDF template.Enter your official contact and identification details.Apply a check mark to indicate the choice wherever necessary.More items You may fax this report to (913) 573-9636or email to backflow@bpu.com Please ONLY submit PASSING test results. Title: Microsoft Word - Backflow Prevention Assembly Test Report.doc Author: RobJ Created Date: 3/3/2009 10:59:44 AM Backflow Prevention Assembly Test Report You may fax this report to (913) 573-9690 or email to backflow@bpu.com. Initial Test Test After Repair. City of Leavenworth. Try for free. I personally inspected and field-tested the backflow assembly using field test procedures meeting WAC 246-290-490 and test I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment. Click here for a list of test gauge calibration facilities. Email Test Reports To: backflow@chesterfield.gov. 2 Leavenworth, Washington, 98826 Directions. Cross Connection Control. *Free Gauge Certifications One free gauge certification and report is available to each enrolled student in a continuing education course. PWS ID# 0610023. Also, the backflow prevention device or assembly must be accessible for inspection and servicing. the . Testers and customers can send any documents regarding backflow questions or issues to ATLbackflowoffice@atlantaga.gov. Contact us at 415.945.1488 or Backflow@MarinWater.org with any questions. Backflow Device Test Witnessed by. Atlanta, GA 30303. Test kit number Certification date of calibration / / Testers name License number Phone Testers signature Contractors business name or stamp Date / You must forward the completed form within 7 days to - Water Protection Officer 972-874-6374. Please ONLY submit PASSING test results. 10340 W State Route 2, Oak Harbor OH 43449. # Sign and date form and indicate NYSDOH (or local health department/water supplier). The following form must be completed for each assembly tested. Denver Water Backflow Assembly Test & Maintenance Report (please print CLEARLY with BLOCK LETTERING) Testing Company: Submit by e-mail (preferred) to 2. Download the form to your computer and open it up with a PDF viewer, such as Adobe Acrobat Reader. Box 287 Leavenworth, Washington, 98826. BACKFLOW ASSEMBLY TEST INSPECTION REPORT . Replacing Model, Make, Serial : New : Part 1: Location & People Information ; Site Address: Owner Name: Day Phone: 9/27/2016 university of florida treeo center test and maintenance report customer: street address: mailing address: location of Reduced Pressure Principle Assembly Double Check Valve Assembly Backflow Prevention Assembly Test Report Return Legible and Satisfactory Reports to: WATER UTILITY AUTHORITY - COMPLIANCE DIVISION CROSS CONNECTION CONTROL OFFICE - Tacoma, WA 98411-0007 . 2020 Water Quality Report; 2020 Water Quality Reports (Johnston) 2020 Water Quality Report (Whipple) 2019 Financial Report; About Us. Mail: Cross Existing Model, Make, Serial . Commercial and residential customers are responsible for submitting annual backflow test results to the Town. BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT The following form must be completed for each assembly tested. After completion, submit copies of test reports to the supplier of Get Backflow Test Report Pdf Get form. If you need to include more information than the form will accept, please attach a supplement For more information on Fairfields backflow program, including access to blank test report forms Print Name Signature Final Test By: Company Tester Ph. MAPAC-006-2009: Premises isolation backflow preventer installation up to 1 size with thermal expansion relief valve. Reduced Pressure Principle Assembly Double Check Valve Assembly BPU Form This course will cover the basic information needed to understand the concepts and fundamentals of cross connection control. Repairs, maintenance, Replacement on sprinkler and valves. The construction site will have several pipes that carry water, waste, or both. Bac-Flo Unlimited offers the most comprehensive backflow training courses with free troubleshooting assistance after 24 or 40 hour course completion. Backflow Prevention Assembly Test Report You may fax this report to (913) 573-9690 or email to backflow@bpu.com. BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT. The following numbers refer to the enclosed form. You may fax this report to (913) 573-9636or email to backflow@bpu.com Please ONLY submit PASSING test results. BACKFLOW . Backflow Assembly Test Report. All backflow test results must be submitted through the Online Backflow Test Entry System. Contact (937) 781-2631 to become an approved tester. Specialties: Backflow testing, Maintenance, Repairs, and Replacement For Backflow Emergency Call Me Anytime. Registration form and required documents may be Fax to: 952-953-2515 Attention: Inspections : ail to: Building Inspections,M 7100 147. th. test and maintennce report rp clean. Important Notice. Click Here for the requirements to register with the City of Houston as a backflow prevention assembly tester. Backflow Prevention Device Test Report Hampton Roads Area Name of Premises: Service Address: Use and location of Device: Device: Certification: I have made the above test and hereby certify that this Backflow Prevention Device performs satisfactorily and meets all Federal, state and local codes and regulations as required.