Backflow Prevention Assembly Test Report

Name of premise

Address

Location of assembly

Manufacturer (Make)

Model

Serial No.

Size

Condition of assembly

Existing

New

Replacement

Serial no. of assembly being replaced

Type of assembly

RPBA

DCVA

PVBA

RPDA

DCDA

Line pressure at time of test

psig

Reduced Pressure Assemblies

Relief valve opening point

psid

Apparent pressure drop

psid

Check valve #2

Closed tight

Leaked

Static (actual) pressure drop

psid

Buffer

psid

Inspection of approved air gap

Pass

Fail

Assembly

Pass

Fail

Double Check Assemblies

Check valve #1

Closed tight

Leaked

Check valve #2

Closed tight

Leaked

Assembly

Pass

Fail

Pressure Vacuum Breaker

Air inlet valve opening point

psid

Did not open

Check valve pressure drop

psid

Leaked

Assembly

Pass

Fail

If an assembly has FAILED, please submit a separate test report after repairs.

Submitter Information

Test performed by

Certification No.

Date test performed

Business name

Business address

Business phone

Business email

Test gauge model no.

Test gauge serial no.

Test gauge calibration date

Acknowledgement

I certify that I have tested the above assembly and that it meets the performance requirements outlined in the CSA B64.10.

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Last updated: November 13, 2024

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