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Backflow Prevention Assembly Test Report
Please submit to the City’s Cross Connection Control Officer
City of Maple Ridge Revised 2016-04-27
11995 Haney Place, Maple Ridge, BC V2X 6A9 Tel: 604-467-7311 Fax: 604-467-7461
Inspection Requests: inspectionrequests@mapleridge.ca Web Site: www.mapleridge.ca Inquiries at: permits@mapleridge.ca
Address of Assembly: Occupant
Owner of Assembly: Owner Contact
Address of Owner: Postal code: Telephone: (_____) - _____ - ______
Assembly: Existing New Replacement
Location of Assembly in Building:
Serial #: Model: Make: Size:
Line Pressure at Time of Test: ______________ PSI. If the test is for an Air Gap, is minimum gap requirement provided? Yes No
Type of Assembly: RPBA RPDA DCVA DCDA PVBA SVBA AG Hazard Level
Premise Isolation if not, specify type of protection (choose one): Irrigation Fire Sprinkler Boiler feed Pool
Air Conditioner Medical Equipment Refrigeration Other
Reduced Pressure Assemblies
Pressure Vacuum Breaker Double Check Assemblies
Check Valve # 1 (A) Check Valve # 2 Relief Valve
(B)
Buffer (C)
(A-B=C)
Air Inlet Check Valve
Initial Test *DC-closed tight?
Yes No
____________ psid
** RP –actual
pressure drop
____________ psid
*Closed tight?
Yes No
____________ psid
**Opened at
_______ psid
PASSED
FAILED
**
_______ psid
* Opened at
_______ psid
Did valve open?
YES NO
*Pressure
Drop _______ psid
Closed right?
YES NO
Test After
Repair
*DC-closed tight?
Yes No
** RP –actual
pressure drop
____________ psid
*Closed tight?
Yes No
____________ psid
**Opened at
_______ psid
PASSED
FAILED
**
_______ psid
*Opened at
_______ psid
Actual pressure
drop
_______ psid
Note: * mandatory for RPBA, RPDA, DCVA ** mandatory for RPBA & RPDA
To the best of your knowledge was the assembly installed correctly? Yes No Explain
*Initial Test Date: *Test Performed by:
*Company Name: Company Phone # & E-mail:
*Make of test kit *Model # *Calibration Date *Serial #
Comments or reason for failure:
I certify that I have tested the above assembly and that the test meets the performance requirements outlined in the City
of Maple Ridge Water Service Bylaw No.: 6645-2009.
Tester’s Signature: ___________________________________ Tester’s Certification #: __________________