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Backflow Prevention Device Test Report

  1. CrossConnectionformBanner3

  2. Specify Device*

  3. An individual backflow prevention device test report must be submitted for each device type being tested.

  4. Enter the initial test result - psid (A)

  5. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

  6. Describe any repairs made

  7. Enter the retest result - psid (A)

  8. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

  9. Enter the initial test result - psid

  10. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

  11. Describe any repairs made

  12. Enter the retest result - psid

  13. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

  14. Enter the initial test result - psid (B)

  15. Did the initial check meet the requirement?

    Requirement: must open with a minimum of 2.0 psid

  16. Describe any repairs made

  17. Enter the retest result - psid (B)

  18. Did the retest meet the requirement?

    Requirement: must open with a minimum of 2.0 psid

  19. Enter the initial test result - psid

  20. Did the initial check meet the requirement?

    Requirement: A - B is greater than or equal to 3.0. psid

  21. Describe any repairs made

  22. Enter the retest result - psid

  23. Did the retest meet the requirement?

    Requirement: A - B is greater than or equal to 3.0 psid

  24. Enter the initial test result - psid

  25. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

  26. Describe any repairs made

  27. Enter the retest result - psid

  28. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

  29. Enter the initial test result - psid

  30. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

  31. Describe any repairs made

  32. Enter the retest result - psid

  33. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

  34. Enter the initial test result - psid

  35. Did the initial check meet the requirement?

    Requirement: opened with a minimum of 1.0 psid

  36. Describe any repairs made

  37. Enter the retest result - psid

  38. Did the retest meet the requirement?

    Requirement: opened with a minimum of 1.0 psid

  39. Enter the initial test result - psid

  40. Did the initial check meet the requirement?

    Requirement: pressure drop/differential at a minimum of 1.0 psid

  41. Describe any repairs made

  42. Enter the restest result - psid

  43. Did the retest meet the requirement?

    Requirement: pressure drop/differential at a minimum of 1.0 psid

  44. Final Results

  45. New Test Certification

    A NEW OR REPLACEMENT DEVICE REQUIRES A PERMIT. I have made the above test and hereby certify that this backflow prevention device performed satisfactorily and meets all federal, state and local codes and regulations as required.

  46. Type of Test*

  47. License/Certificate*

  48. Address: 6040 Waterworks Rd., Norfolk, VA 23502

    O: 757-441-5774 ext. 262 M: 757-620-2781 Fax: 757-441-5639 Email: UTBackflow@norfolk.gov

  49. Water and Sewer Main Break 24-HR Emergency 757-820-1000

  50. Leave This Blank:

  51. This field is not part of the form submission.