Form 7 "Backflow Prevention Device Inspection and Maintenance Report Form" - Massachusetts

What Is Form 7?

This is a legal form that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 20, 2014;
  • The latest edition provided by the Massachusetts Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 7 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Environmental Protection.

ADVERTISEMENT
ADVERTISEMENT

Download Form 7 "Backflow Prevention Device Inspection and Maintenance Report Form" - Massachusetts

211 times
Rate (4.8 / 5) 15 votes
INSPECTION AND
BACKFLOW PREVENTION DEVICE
Initial Test
MAINTENANCE REPORT FORM
(Print Clearly)
Annual Test (DCVA / PVB / SRPVB)
Semi-annual Test (RPBP)
_____/______/______/______/______/______/______
_________________________________________________________
PWS ID#
Public Water System Name
________________________________________________________
________________________________________________________
Facility Name
Facility Address
, MA
_________________________________________________________
_______________________________________
_____________
Facility Owner Name/Responsible Party
City/Town
Zip
_____________________________________, ______ ___________
___________________________________________________________
City/Town
State
Zip
Mailing Address
(_________)__________-________________ ext. ________________
________________________________________________________
Phone #
Owner Name/Owner Rep. Name/Contact Person
Exact location of cross-connection __________________
Cross-connection Info: ID #
__________________________
_________________________________________________________
Backflow Preventer Info.:
_________________________
____________
____________”
___________________
Make
M
odel
Size
Serial #
Yes
No
Supplemental protection at meter required:
Material:
Bronze
Iron
Stainless Steel
Shutoff Valve Type:
Ball
NRS
OS&Y
Butterfly
Other
_________________________________________
:
Yes
No
Yes __________________
No
By-pass
Auxiliary Supply:
:
Installation:
Vertically
Horizontally
Installation required by
State
Local
Yes
No
Are repair parts available on site?
Serv. Type:
Domestic
Fire Protec.
Irrigation
Yes
No
Is the installation of this backflow preventer in compliance with the requirements of 310 CMR 22.22(11)?
Make
Model
Serial #
Last Calibration
Test Kit Information
_____________
_______________
___________
____/____/____
RPBP
PVB
SRPVB
DCVA
st
nd
1
Check
2
Check
Relief Valve
Air Inlet
Check Valve
Closed Tight
Closed Tight
Open at ___ psid
Open at ____
Open at ____
psid
psid
Held at ______ psid
Held at _____ psid
Test Date
Did not open
Did not pen
Leaked
Leaked
Leaked
_______/_______/_______
nd
2
Shutoff
Closed
Leaked
Valve
Tight
*
Test Result
PASS
FAIL
I hereby certified that I have personally tested the above backflow prevention device/assembly in accordance with
the method and procedure that I was trained, and the test result is true and shows that the device/assembly is in
proper operating condition. (Signatures required)
Backflow Device Test Conducted by a MassDEP Certified Backflow Prevention Device Tester
___________________________ _______________
____/____/____
________________________
(_____)_____-_________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by a Facility Owner/Representative
__________________________________ ________________________ _________________________
____/____/____
Facility Owner/Representative Name (Print)
Title
Signature
Date
*
If a backflow prevention device failed a test, the following steps are required by the Massachusetts Drinking Water Regulations:
The owner of the device must obtain the service of a Massachusetts licensed plumber or a Massachusetts licensed fire sprinkler
fitter/contractor to perform the necessary repair within fourteen (14) calendar days of the failure test or from the discovery of the defect
as required by the Massachusetts Drinking Water Regulations, 310 CMR 22.22(13)(b). The repaired device must be re-tested by a
Massachusetts certified backflow prevention device tester.
A Backflow Prevention Device Repair Information & Re-test Report Form must be completed to report the repair(s) conducted and
to report the re-test result.
P://OPS/Xconn/Inspection & Maintenance Report Form #7 rev. 05/20/2014
INSPECTION AND
BACKFLOW PREVENTION DEVICE
Initial Test
MAINTENANCE REPORT FORM
(Print Clearly)
Annual Test (DCVA / PVB / SRPVB)
Semi-annual Test (RPBP)
_____/______/______/______/______/______/______
_________________________________________________________
PWS ID#
Public Water System Name
________________________________________________________
________________________________________________________
Facility Name
Facility Address
, MA
_________________________________________________________
_______________________________________
_____________
Facility Owner Name/Responsible Party
City/Town
Zip
_____________________________________, ______ ___________
___________________________________________________________
City/Town
State
Zip
Mailing Address
(_________)__________-________________ ext. ________________
________________________________________________________
Phone #
Owner Name/Owner Rep. Name/Contact Person
Exact location of cross-connection __________________
Cross-connection Info: ID #
__________________________
_________________________________________________________
Backflow Preventer Info.:
_________________________
____________
____________”
___________________
Make
M
odel
Size
Serial #
Yes
No
Supplemental protection at meter required:
Material:
Bronze
Iron
Stainless Steel
Shutoff Valve Type:
Ball
NRS
OS&Y
Butterfly
Other
_________________________________________
:
Yes
No
Yes __________________
No
By-pass
Auxiliary Supply:
:
Installation:
Vertically
Horizontally
Installation required by
State
Local
Yes
No
Are repair parts available on site?
Serv. Type:
Domestic
Fire Protec.
Irrigation
Yes
No
Is the installation of this backflow preventer in compliance with the requirements of 310 CMR 22.22(11)?
Make
Model
Serial #
Last Calibration
Test Kit Information
_____________
_______________
___________
____/____/____
RPBP
PVB
SRPVB
DCVA
st
nd
1
Check
2
Check
Relief Valve
Air Inlet
Check Valve
Closed Tight
Closed Tight
Open at ___ psid
Open at ____
Open at ____
psid
psid
Held at ______ psid
Held at _____ psid
Test Date
Did not open
Did not pen
Leaked
Leaked
Leaked
_______/_______/_______
nd
2
Shutoff
Closed
Leaked
Valve
Tight
*
Test Result
PASS
FAIL
I hereby certified that I have personally tested the above backflow prevention device/assembly in accordance with
the method and procedure that I was trained, and the test result is true and shows that the device/assembly is in
proper operating condition. (Signatures required)
Backflow Device Test Conducted by a MassDEP Certified Backflow Prevention Device Tester
___________________________ _______________
____/____/____
________________________
(_____)_____-_________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by a Facility Owner/Representative
__________________________________ ________________________ _________________________
____/____/____
Facility Owner/Representative Name (Print)
Title
Signature
Date
*
If a backflow prevention device failed a test, the following steps are required by the Massachusetts Drinking Water Regulations:
The owner of the device must obtain the service of a Massachusetts licensed plumber or a Massachusetts licensed fire sprinkler
fitter/contractor to perform the necessary repair within fourteen (14) calendar days of the failure test or from the discovery of the defect
as required by the Massachusetts Drinking Water Regulations, 310 CMR 22.22(13)(b). The repaired device must be re-tested by a
Massachusetts certified backflow prevention device tester.
A Backflow Prevention Device Repair Information & Re-test Report Form must be completed to report the repair(s) conducted and
to report the re-test result.
P://OPS/Xconn/Inspection & Maintenance Report Form #7 rev. 05/20/2014