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2. 
4. BACKFLOW TEST REPORT FORM
   FAILED test results must be reported to the Cañon City Water Department within 24 hours of failure at (719) 269-9022.

6. Assembly Serial #
7. Test Date/Time
   Test Date/Time

   Test Date/Time
9. Tester Certification Number
10. Assembly Test Results

    1. Pass
    2. Fail
14. ACCOUNT
16. Facility Name
17. Meter #
19. Facility Address
21. City
22. State
23. Zip Code
25. Contact Person
26. Phone Number
30. ASSEMBLY
32. Make
33. Model
35. Type

    1. RP
    2. DC
    3. PVB
    4. SVB
    5. Air Gap
36. Size
37. Date Installed
39. Condition

    1. New
    2. Existing
40. Previous Assembly #
41. Location
43. Type of Use

    1. Domestic
    2. Fire
    3. Glycol
    4. Irrigation
    5. Recyled
44. Protection

    1. Containment
    2. Containment by Isolation
    3. Isolation
45. Orientation - Inlet

    1. Horizontal
    2. Vertical Up
    3. Vertical Down
46. Orientation - Outlet

    1. Horizontal
    2. Vertical Up
    3. Vertical Down
48. Approved

    1. Yes
    2. No
52. TESTING & MAINTENANCE
54. Line PSI
58. Check Valve #1

    RP, DC, PVB

59. Check Valve #2

    RP, DC

61. Initial Test Results

    Tightness

    1. Leak
    2. Tight
62. Initial Test Results

    Tightness

    1. Leak
    2. Tight
64. Differential
65. Differential
67. Repairs
68. Repairs
70. Re-Test Results

    Tightness

    1. Leak
    2. Tight
71. Re-Test Results

    Tightness

    1. Leak
    2. Tight
73. Differential
74. Differential
78. Relief Valve

    RP

79. Buffer

    RP

80. Air Inlet

    PVB

82. Initial Test Results - Differential
83. Initial Test Results - Differential
84. Initial Test Results - Differential
86. Repairs
87. Repairs
88. Repairs
90. Re-Test Results – Differential
91. Re-Test Results – Differential
92. Re-Test Results – Differential
96. Shutoff Valve #1

    1. Tight
    2. Leaking
    3. Replaced
97. Shutoff Valve #2

    1. Tight
    2. Leaking
    3. Replaced
98. Backpressure

    1. Yes
    2. No
99. Test Procedure

    1. ABPA
    2. ASSE
101. Comments
105. NOTIFICATION
107. Alarm Company / Fire Department
109. Person Notified
110. Contacted By
112. Turn Off Date/Time
     Turn Off Date/Time

     Turn Off Date/Time
113. Turn On Date/Time
     Turn On Date/Time

     Turn On Date/Time
117. TEST KIT
119. Test Kit Make
120. Model
122. Serial #
123. Last Calibration Date
127. TESTER

     Tester certifies this assembly has been tested with the above listed procedure and verifies the isolation valves were returned to pre-test orientation.

129. Testing Company
130. Tester Name
132. Phone
133. Certificate Expiration Date
135. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
137. Electronic Signature

141. City of Cañon City Water Department

     Office Hours:  Monday– Friday  7:00 a.m.–3:30 p.m.
     719.269.9022
     backflowreporting@canoncity.org

     
     

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144. Email address

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