Get Backflow Test Report Form

Backflow Prevention Device Test Report Division Contact Info Steve Miller or Lindley Paynter Office 919-249-3427 Fax 919-367-7280 Town of Apex Work Order REQUIRED ONLY COMPLETED PASSING RESULTS SHALL BE ACCEPTED Public Works Utilities Department - 105 Upchurch Street Apex NC 27502 - CrossConnection apexnc.org Environmental Programs - Cross Connection Control Program To be submitted by the REGISTERED / APPROVED TOWN TESTER. This test report form SHALL be conducted by a CERTIFIED TESTER under Town of Apex Cross Connection Ordinance Municipal Code Chapter 12-156 through 166. In addition the Town requires a BUILDING PERMIT and a NON-SEWER WATER METER to be obtained before any Backflow Prevention installations begin* All test s reports shall beCOMPLETED IN FULL and submitted to the information on the letter head before OPERATION and CERTIFICATE of OCCUPANCY. Facility Name Property Owner Name City Owner Email Zip Code Facility Address Number of Water Meters Onsite Town of Apex Water Meter Account s Located On Any Water Bill Payments Made By The Owner Is this a Fire BFP Detector Assy No REQUIRED Building Permit All New Installs Replacements Unprotected Water Meters Onsite Tester Business Name Tester Address Tester s Cert Test Kit Manufacturer Test Kit Model Assy Serial Test Kit Serial Calibration Expiry Date mm/dd/yyyy Mid-West Specific Location of Assy Assy Manufacturer HotBox Hazard Level Assy Orientation Health Horizontal Assy Install Date Relief Valve C Reduced Pressure Condtiion N/A Check Valve 2 B st Comp Tee and Sight Tube Required Pressure Differential Across 1 Check Valve No Flow A Shut-Off 2 psi Static Inlet Line Pressure Test Result Remarks PSID Check Valve Opened Differential Pressure Buffer 3 psi or Greater D A C D Air Inlet Opened Opening Point Of Relief Valve 2 psi or Greater C PVB DCVA Assy Type Installed By Company Name Domestic Assy Size RP T e s t Assy Model Type Of Test RP Shut-Off 2 DCVA Shut-Off 1 Zurn-Wilkins Shut-Off Valves Tester Phone Did Not Open Test Date mm/dd/yyy Re pa ir If The Device Fails The Initial Test For Any Reason Complete The Sections Below Indicating The Repairs And Retest Results Check Applicable Valve s R I certify that the above device has been tested in accordance with the Town of Apex Municipal Code Chapter 851 and CSA Standard B64. 10. 1-01 Manual for The Maintenance Field Testing of Backflow Prevention Devices Signature Of The Certified Tester Date Signed Reset Form ResetButton Print Button Print Submit Button Submit to Apex CCC. In addition the Town requires a BUILDING PERMIT and a NON-SEWER WATER METER to be obtained before any Backflow Prevention installations begin* All test s reports shall beCOMPLETED IN FULL and submitted to the information on the letter head before OPERATION and CERTIFICATE of OCCUPANCY. Facility Name Property Owner Name City Owner Email Zip Code Facility Address Number of Water Meters Onsite Town of Apex Water Meter Account s Located On Any Water Bill Payments Made By The Owner Is this a Fire BFP Detector Assy No REQUIRED Building Permit All New Installs Replacements Unprotected Water Meters Onsite Tester Business Name Tester Address Tester s Cert Test Kit Manufacturer Test Kit Model Assy Serial Test Kit Serial Calibration Expiry Date mm/dd/yyyy Mid-West Specific Location of Assy Assy Manufacturer HotBox Hazard Level Assy Orientation Health Horizontal Assy Install Date Relief Valve C Reduced Pressure Condtiion N/A Check Valve 2 B st Comp Tee and Sight Tube Required Pressure Differential Across 1 Check Valve No Flow A Shut-Off 2 psi Static Inlet Line Pressure Test Result Remarks PSID Check Valve Opened Differential Pressure Buffer 3 psi or Greater D A C D Air Inlet Opened Opening Point Of Relief Valve 2 psi or Greater C PVB DCVA Assy Type Installed By Company Name Domestic Assy Size RP T e s t Assy Model Type Of Test RP Shut-Off 2 DCVA Shut-Off 1 Zurn-Wilkins Shut-Off Valves Tester Phone Did Not Open Test Date mm/dd/yyy Re pa ir If The Device Fails The Initial Test For Any Reason Complete The Sections Below Indicating The Repairs And Retest Results Check Applicable Valve s R I certify that the above device has been tested in accordance with the Town of Apex Municipal Code Chapter 851 and CSA Standard B64.