Form Center

2. 
4. Business/Owner Name*
5. Phone*
7. Address*
8. Apt./Unit
9. Zip*
11. Use/Location of Device*
13. Device Type*
    -- Select One --RPZDouble Check ValvePressure Vacuum BreakerAnti Spill Vacuum Breaker
14. Manufacturer*
15. Size*
17. Model #*
18. Serial #*
20. Line Pressure at Time of Test*
21. Specify Device*

    1. Existing
    2. Replacement
    3. New
22. Enter Removed Device's Serial Number
24. An individual backflow prevention device test report must be submitted for each device type being tested.
26. Step 1 - Check Valve #1
    Enter the initial test result - psid (A)
27. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

    1. Yes
    2. No
29. Repairs
    Describe any repairs made
30. Retest valve #1
    Enter the retest result - psid (A)
31. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

    1. Yes
    2. No
33. Step 2 - Check Valve #2
    Enter the initial test result - psid
34. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

    1. Yes
    2. No
36. Repairs
    Describe any repairs made
37. Retest valve #2
    Enter the retest result - psid
38. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 5.0 psid

    1. Yes
    2. No
40. Step 3 - Check the Differential Pressure Relief Port
    Enter the initial test result - psid (B)
41. Did the initial check meet the requirement?

    Requirement: must open with a minimum of 2.0 psid

    1. Yes
    2. No
43. Repairs
    Describe any repairs made
44. Retest the differential pressure relief port
    Enter the retest result - psid (B)
45. Did the retest meet the requirement?

    Requirement: must open with a minimum of 2.0 psid

    1. Yes
    2. No
47. Step 4 - Check the Pressure Buffer
    Enter the initial test result - psid
48. Did the initial check meet the requirement?

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

    1. Yes
    2. No
50. Repairs
    Describe any repairs made
51. Retest the pressure buffer
    Enter the retest result - psid
52. Did the retest meet the requirement?

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

    1. Yes
    2. No
54. Step 1 - Check Valve #1
    Enter the initial test result - psid
55. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

    1. Yes
    2. No
57. Repairs
    Describe any repairs made
58. Retest valve #1
    Enter the retest result - psid
59. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

    1. Yes
    2. No
61. Step 2 - Check Valve #2
    Enter the initial test result - psid
62. Did the initial check meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

    1. Yes
    2. No
64. Repairs
    Describe any repairs made
65. Retest valve #2
    Enter the retest result - psid
66. Did the retest meet the requirement?

    Requirement: closed tight with a minimum of 1.0 psid

    1. Yes
    2. No
68. Step 1 - Check Air Inlet
    Enter the initial test result - psid
69. Did the initial check meet the requirement?

    Requirement: opened with a minimum of 1.0 psid

    1. Yes
    2. No
71. Repairs
    Describe any repairs made
72. Retest air inlet
    Enter the retest result - psid
73. Did the retest meet the requirement?

    Requirement: opened with a minimum of 1.0 psid

    1. Yes
    2. No
75. Step 2 - Check Valve
    Enter the initial test result - psid
76. Did the initial check meet the requirement?

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

    1. Yes
    2. No
78. Repairs
    Describe any repairs made
79. Retest valve

    Enter the retest result - psid

80. Did the retest meet the requirement?

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

    1. Yes
    2. No
82. Final Results

    1. Device passed
    2. Device failed
83. Remarks
85. 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.
87. Type of Test*

    1. New
    2. Retest
89. Tester Signature*
90. Date*
    Date
92. Test Kit Serial Number*
93. Calibration Date*
    Calibration Date
95. License/Certificate*

    1. DPOR
    2. Norfolk
96. Other:
97. License #*
98. Expiration Date*
    Expiration Date
100. Testing Company Name*
101. Phone #*
103. Address*
104. Apt./Unit
106. City*
107. State*
108. Zip*
110. Thank you for protecting Norfolk tap water!
     Visit our Cross Connections page for more information.

     Norfolk Department of Utilities - Division of Water Quality
112. 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
114. Water and Sewer Main Break 24-HR Emergency 757-820-1000
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

* indicates a required field