Form 0305B "Backflow Prevention Assembly Test Data and Maintenance Report" - St. Louis County, Missouri

What Is Form 0305B?

This is a legal form that was released by the Department of Public Works - St. Louis County, Missouri - a government authority operating within Missouri. The form may be used strictly within St. Louis County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a printable version of Form 0305B by clicking the link below or browse more documents and templates provided by the Department of Public Works - St. Louis County, Missouri.

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Download Form 0305B "Backflow Prevention Assembly Test Data and Maintenance Report" - St. Louis County, Missouri

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StLCO Form: Test Rpt 0305b
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
Customer:
Mailing Address:
City and State:
Zip Code
Address of Location of Back-Flow Device:
Describe physical location of Back-Flow Device:
Manufacturer:
Model:
Size:
Serial Number:
Type Of Device: ________ Air Gap
_______ DC _______ RP ________ PVB
Application :
(from MO part 10.CSR 11.010):
Device protected from:
Air Gap (2 x Supply Diameter)
__________ Containment
Hazard Class _________
_____ Freezing
Supply ________ in
_______ Pass
__________ Isolation
Hazard Item
_________
_____ Flooding
Gap ___________in
_______ Fail
Date Of Test
Describe the Equipment that the Back-Flow Device Services
Height Off Floor
________________(FT/IN)
Permit Information
Installation Status
Type Of System
Number_________________________
New_____
Existing_______
Fire Suppression _____ Process Piping ____
Contractor____________________________
Is the assembly properly tagged?
Lawn Irrigation ______
Plumbing _______
Permit Date___________________________
Yes______
No________
Other _______________________________
INITIAL TEST_____ FINAL TEST______
PASSED
FAILED
INITIAL TEST____ FINAL TEST_____ PASSED
FAILED
Reduced Pressure Assembly:
Double Check Valve Assembly:
st
1
CHECK held in direction of flow
st
1
CHECK held in direction of flow
_____ PSID (5 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
RELIEF VALVE opened at
nd
2
CHECK held backpressure
________
_______
_____ PSID (2 PSID or more)
________
_______
No. 2 Shut-off Valve leak tight
________
_______
st
DIFFERENCE (1
check-relief)
nd
2
CHECK held in direction of flow
_____ PSID (3 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
nd
2
CHECK held backpressure
________
_______
_______________________________________________________
No. 2 Shut-off Valve leak tight
________
_______
FINAL TEST _______ PASSED _______ FAILED
OPTIONAL TEST
Pressure Vacuum Breaker Assembly:
Relief Valve (exercised to open Position)
________
_______
Test #1 Shutoff Valve
___________________________________________________________
- held pressure tight.
________
_______
Comments:
Test CHECK VALVE held in direction
___________________________________________________________
of flow ________ PSID (1 PSID or more)
________
_______
___________________________________________________________
Test AIR INLET VALVE to open
___________________________________________________________
________ PSID (1 PSID or more)
________
_______
PVB may not be repaired, must be replaced
___________________________________________________________
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
Tested By: (Print name and provide Signature)
Repaired By: (Print name and provide Signature)
Company
Final Test By: (Print name and provide Signature)
Certification Number And Expiration Date
Owner Or Owner’s Representative
Date
1. This form is to be used and sent to St. Louis County for a failed test as well as a passed test.
Do not use one form for both the failed and passed test. Use a separate form for each.
2. This form must be filed within 30 days of test per state regulations and St. Louis County Ordinance.
3. Tester must sign this form.
C:\Documents and Settings\pw0l0b.000\Desktop\0305b Backflow Form.doc
StLCO Form: Test Rpt 0305b
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
Customer:
Mailing Address:
City and State:
Zip Code
Address of Location of Back-Flow Device:
Describe physical location of Back-Flow Device:
Manufacturer:
Model:
Size:
Serial Number:
Type Of Device: ________ Air Gap
_______ DC _______ RP ________ PVB
Application :
(from MO part 10.CSR 11.010):
Device protected from:
Air Gap (2 x Supply Diameter)
__________ Containment
Hazard Class _________
_____ Freezing
Supply ________ in
_______ Pass
__________ Isolation
Hazard Item
_________
_____ Flooding
Gap ___________in
_______ Fail
Date Of Test
Describe the Equipment that the Back-Flow Device Services
Height Off Floor
________________(FT/IN)
Permit Information
Installation Status
Type Of System
Number_________________________
New_____
Existing_______
Fire Suppression _____ Process Piping ____
Contractor____________________________
Is the assembly properly tagged?
Lawn Irrigation ______
Plumbing _______
Permit Date___________________________
Yes______
No________
Other _______________________________
INITIAL TEST_____ FINAL TEST______
PASSED
FAILED
INITIAL TEST____ FINAL TEST_____ PASSED
FAILED
Reduced Pressure Assembly:
Double Check Valve Assembly:
st
1
CHECK held in direction of flow
st
1
CHECK held in direction of flow
_____ PSID (5 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
RELIEF VALVE opened at
nd
2
CHECK held backpressure
________
_______
_____ PSID (2 PSID or more)
________
_______
No. 2 Shut-off Valve leak tight
________
_______
st
DIFFERENCE (1
check-relief)
nd
2
CHECK held in direction of flow
_____ PSID (3 PSID or more)
________
_______
______ PSID (1 PSID or more)
________
_______
nd
2
CHECK held backpressure
________
_______
_______________________________________________________
No. 2 Shut-off Valve leak tight
________
_______
FINAL TEST _______ PASSED _______ FAILED
OPTIONAL TEST
Pressure Vacuum Breaker Assembly:
Relief Valve (exercised to open Position)
________
_______
Test #1 Shutoff Valve
___________________________________________________________
- held pressure tight.
________
_______
Comments:
Test CHECK VALVE held in direction
___________________________________________________________
of flow ________ PSID (1 PSID or more)
________
_______
___________________________________________________________
Test AIR INLET VALVE to open
___________________________________________________________
________ PSID (1 PSID or more)
________
_______
PVB may not be repaired, must be replaced
___________________________________________________________
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
Tested By: (Print name and provide Signature)
Repaired By: (Print name and provide Signature)
Company
Final Test By: (Print name and provide Signature)
Certification Number And Expiration Date
Owner Or Owner’s Representative
Date
1. This form is to be used and sent to St. Louis County for a failed test as well as a passed test.
Do not use one form for both the failed and passed test. Use a separate form for each.
2. This form must be filed within 30 days of test per state regulations and St. Louis County Ordinance.
3. Tester must sign this form.
C:\Documents and Settings\pw0l0b.000\Desktop\0305b Backflow Form.doc