"Backflow Prevention Device Repair Information & Re-test Report Form" - Massachusetts

Backflow Prevention Device Repair Information & Re-test Report Form is a legal document that was released by the Massachusetts Department of Environmental Protection - a government authority operating within Massachusetts.

Form Details:

  • Released on July 5, 2012;
  • The latest edition currently provided by the Massachusetts Department of Environmental Protection;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

ADVERTISEMENT
ADVERTISEMENT

Download "Backflow Prevention Device Repair Information & Re-test Report Form" - Massachusetts

392 times
Rate (4.5 / 5) 26 votes
BACKFLOW PREVENTION DEVICE REPAIR INFORMATION &
RE-TEST REPORT FORM
(Print Clearly)
Please Note:
Prior to repair contact the local Plumbing Dept. or Fire Dept. to find out if a permit is required for the
repair of backflow prevention device/assembly.
Backflow Preventer Failed:
RPBP
DCVA
PVB/SRPVB
______________
_____________
______”
____________
_______________________________
Make
Model
Size
Serial #
Location
For Devices Located on Domestic Line: a Massachusetts Licensed Plumber must conduct the repair of these devices.
____________________________ ________________
____/____/____
____________________
____/____/____
MA License Plumber’s Name (Print) Plumber License #
Expiration Date
Signature
Date
__________________________
________________
____/____/_____
___________________
____/____/____
Plumbing Inspector’s Name (Print) Plumber License #
Expiration Date
Signature
Date
For Devices Located on Fire Protection Line: a Massachusetts Certified Fire Sprinkler Fitter/Contractor must conduct the
repairs of these devices.
_________________________________
____________ ____/____/____
____________________
____/___/____
MA Licensed Fire Sprinkler Installer Name License #
Expiration Date
Signature
Date
Repair Date
Check Valve #1
Check Valve #2
Relief Valve
______/______/______
Cleaned only
Cleaned only
Cleaned only
Part(s) Replaced:
Part(s) Replaced:
Part(s) Replaced:
 Disc
 Spring
 Disc
 Spring
 Disc, upper
 Disc, lower
Describe Repair(s)
 Guide
 Pin Retainer
 Guide
 Pin Retainer
 Spring
 O-Rings
 Hinge Pin
 Seat
 Hinge Pin
 Seat
Diaphragm (large) upper lower
 Diaphragm  O-Rings
 Diaphragm  O-Rings
Diaphragm (small) upper lower
 Module
 Module
 Space (lower)
 Module
 Other _________________
 Other _________________
 Other ______________________
Test Kit
Make
Model
Serial #
Last Calibration
Information
________________
___________
______________
_____/_____/_____
RPBP
PVB/SRPVB
Test After
DCVA
Relief Valve
Repair
st
nd
1
Check
2
Check
Air Inlet
Check Valve
Closed Tight
Closed Tight
Re-test Date
Open at _______
______ psid
Open at ____
psid
psid
Held at ______ psid
Held at ______ psid
______/______/______
Leaked
Did not open
Leaked
Leaked
nd
2
Shutoff Valve
Closed Tight
Leaked
Re-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 Backflow Prevention Device Tester
___________________________ ______________
_____/____/____
________________________
(_____)______-__________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by the Facility Owner/Representative
_______________________________
___________________________
___________________________
_____/_____/_____
Facility Owner/Representative Name (Print)
Title
Signature
*
If repaired backflow prevention device fails the re-test, it must be repaired and re-test and a Backflow Prevention
Device Repair Information & Re-test Report Form must be filling out.
P://OPS/Xconn/Repair & Re-test Form rev. 07/05/2012
BACKFLOW PREVENTION DEVICE REPAIR INFORMATION &
RE-TEST REPORT FORM
(Print Clearly)
Please Note:
Prior to repair contact the local Plumbing Dept. or Fire Dept. to find out if a permit is required for the
repair of backflow prevention device/assembly.
Backflow Preventer Failed:
RPBP
DCVA
PVB/SRPVB
______________
_____________
______”
____________
_______________________________
Make
Model
Size
Serial #
Location
For Devices Located on Domestic Line: a Massachusetts Licensed Plumber must conduct the repair of these devices.
____________________________ ________________
____/____/____
____________________
____/____/____
MA License Plumber’s Name (Print) Plumber License #
Expiration Date
Signature
Date
__________________________
________________
____/____/_____
___________________
____/____/____
Plumbing Inspector’s Name (Print) Plumber License #
Expiration Date
Signature
Date
For Devices Located on Fire Protection Line: a Massachusetts Certified Fire Sprinkler Fitter/Contractor must conduct the
repairs of these devices.
_________________________________
____________ ____/____/____
____________________
____/___/____
MA Licensed Fire Sprinkler Installer Name License #
Expiration Date
Signature
Date
Repair Date
Check Valve #1
Check Valve #2
Relief Valve
______/______/______
Cleaned only
Cleaned only
Cleaned only
Part(s) Replaced:
Part(s) Replaced:
Part(s) Replaced:
 Disc
 Spring
 Disc
 Spring
 Disc, upper
 Disc, lower
Describe Repair(s)
 Guide
 Pin Retainer
 Guide
 Pin Retainer
 Spring
 O-Rings
 Hinge Pin
 Seat
 Hinge Pin
 Seat
Diaphragm (large) upper lower
 Diaphragm  O-Rings
 Diaphragm  O-Rings
Diaphragm (small) upper lower
 Module
 Module
 Space (lower)
 Module
 Other _________________
 Other _________________
 Other ______________________
Test Kit
Make
Model
Serial #
Last Calibration
Information
________________
___________
______________
_____/_____/_____
RPBP
PVB/SRPVB
Test After
DCVA
Relief Valve
Repair
st
nd
1
Check
2
Check
Air Inlet
Check Valve
Closed Tight
Closed Tight
Re-test Date
Open at _______
______ psid
Open at ____
psid
psid
Held at ______ psid
Held at ______ psid
______/______/______
Leaked
Did not open
Leaked
Leaked
nd
2
Shutoff Valve
Closed Tight
Leaked
Re-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 Backflow Prevention Device Tester
___________________________ ______________
_____/____/____
________________________
(_____)______-__________
Backflow Tester Name (Print)
MassDEP Cert.ID#
Exp. Date
Signature
Phone#
Backflow Device Test Witnessed by the Facility Owner/Representative
_______________________________
___________________________
___________________________
_____/_____/_____
Facility Owner/Representative Name (Print)
Title
Signature
*
If repaired backflow prevention device fails the re-test, it must be repaired and re-test and a Backflow Prevention
Device Repair Information & Re-test Report Form must be filling out.
P://OPS/Xconn/Repair & Re-test Form rev. 07/05/2012