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Backflow Prevention Device Test Report

  1. CrossConnectionformBanner3
  2. Specify Device*
  3. An individual backflow prevention device test report must be submitted for each device type being tested.
  4. Enter the initial test result - psid (A)
  5. Did the initial check meet the requirement?
    Requirement: closed tight with a minimum of 5.0 psid
  6. Describe any repairs made
  7. Enter the retest result - psid (A)
  8. Did the retest meet the requirement?
    Requirement: closed tight with a minimum of 5.0 psid
  9. Enter the initial test result - psid
  10. Did the initial check meet the requirement?
    Requirement: closed tight with a minimum of 5.0 psid
  11. Describe any repairs made
  12. Enter the retest result - psid
  13. Did the retest meet the requirement?
    Requirement: closed tight with a minimum of 5.0 psid
  14. Enter the initial test result - psid (B)
  15. Did the initial check meet the requirement?
    Requirement: must open with a minimum of 2.0 psid
  16. Describe any repairs made
  17. Enter the retest result - psid (B)
  18. Did the retest meet the requirement?
    Requirement: must open with a minimum of 2.0 psid
  19. Enter the initial test result - psid
  20. Did the initial check meet the requirement?
    Requirement: A - B is greater than or equal to 3.0. psid
  21. Describe any repairs made
  22. Enter the retest result - psid
  23. Did the retest meet the requirement?
    Requirement: A - B is greater than or equal to 3.0 psid
  24. Enter the initial test result - psid
  25. Did the initial check meet the requirement?
    Requirement: closed tight with a minimum of 1.0 psid
  26. Describe any repairs made
  27. Enter the retest result - psid
  28. Did the retest meet the requirement?
    Requirement: closed tight with a minimum of 1.0 psid
  29. Enter the initial test result - psid
  30. Did the initial check meet the requirement?
    Requirement: closed tight with a minimum of 1.0 psid
  31. Describe any repairs made
  32. Enter the retest result - psid
  33. Did the retest meet the requirement?
    Requirement: closed tight with a minimum of 1.0 psid
  34. Enter the initial test result - psid
  35. Did the initial check meet the requirement?
    Requirement: opened with a minimum of 1.0 psid
  36. Describe any repairs made
  37. Enter the retest result - psid
  38. Did the retest meet the requirement?
    Requirement: opened with a minimum of 1.0 psid
  39. Enter the initial test result - psid
  40. Did the initial check meet the requirement?
    Requirement: pressure drop/differential at a minimum of 1.0 psid
  41. Describe any repairs made
  42. Enter the restest result - psid
  43. Did the retest meet the requirement?
    Requirement: pressure drop/differential at a minimum of 1.0 psid
  44. Final Results
  45. New Test Certification
    A NEW OR REPLACEMENT DEVICE REQUIRES A PERMIT. I have made the above test and hereby certify that this backflow prevention device performed satisfactorily and meets all federal, state and local codes and regulations as required.
  46. Type of Test*
  47. License/Certificate*
  48. Address: 6040 Waterworks Rd., Norfolk, VA 23502
    O: 757-441-5774 ext. 262 M: 757-620-2781 Fax: 757-441-5639 Email: UTBackflow@norfolk.gov
  49. Water and Sewer Main Break 24-HR Emergency 757-820-1000
  50. Leave This Blank:

  51. This field is not part of the form submission.