9f Reportoninspectionandtesting

1 March 2006, Version 1

Plumbing and Drainage Act 2002

(s. 38 SPDR)

REPORT ON INSPECTION AND TESTING OF BACKFLOW PREVENTION Plumbing and Drainage Act 2002 DEVICES, REGISTERED AIR GAPS AND REGISTERED BREAK TANKS 1. Application and type of test

File Reference or BA:

First test (New device) Retest

Standard Test Audit test

2. Owner/occupier and tester’s details

Owner/Occupier Name

Authorised Tester’s Name

Address

Licence Number

Contact Person

Address

Phone No/Mobile No.

Phone No/Mobile No.

9

Date of test

Site Address

3. Backflow prevention device and

Location of Device

test results

.

Make and type

Size

Containment Protection

Model No

Zone Protection

Describe maintenance & parts & materials used Test after maintenance

Individual protection Pressure Type Vacuum-Breaker

Reduced Pressure Zone Device

Initial test before maintenance

Serial No

Double Check Devices (column 1 & 2) Check Valve No 1 Check Valve No 2 Differential pressure Opened at Double check Closed tight closed tight RP………..….KPA …………KPA ………..KPA Leaked Leaked

Air Inlet

Check Valve

Opened at

…………….KPA ……………KPA Not opened Not opened _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Double check – Closed tight RP…………. KPA

Test Kit Serial No.

Closed tight

…………..KPA

Opened at

Opened at

….……..KPA

………………KPA

Date Test Kit Last Verified

………….KPA

Plumbers’ Name

Remarks

Plumbers’ Signature

Pass

Fail

OFFICE USE ONLY DATE RECEIVED

RECEIVING OFFICER’S NAME/S

REFERENCE NUMBER/S

Date

4.

Air gap & break tanks details

Location

Inlet Pipe diameter,

Air gap spacing,

Air gap bridged

Yes

d1:------------------------mm

h:---------------------mm

or bypassed:

No

Test date

Tester

Result:

Pass Fail

Describe how air gap was bridged or bypassed: