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', BACKFLOW DEVICE TEST
�F }� 3tate Form 55788 (2-15�
� �r INp1ANA 1JEpAR7MENT pF Ef�lVIRONMEtJTIiL MAhRG�MENT
�f
TNIS FORM lS TD BE COMPLETED BYAN IND/ANA CERTIFlED BACKFLOW TESTER.
1. Customer name
3. C stomer�e s un
,��
4. Lo tion of devic (and
Domestic
8. Type o protection
❑ Isolation
10. ' o�device 11
13. Additional information �
G
code)
customer)
❑ Fire ❑ Irrigation
Containment
nuf�Gturer of dewce
2. Customer company
5. Is the device a new assembly? �Yes ❑ No
Re lacin serial number:
7.,Typ of assembly
�P ❑ DC ❑ PVB ❑ SVB ❑ Air Gap ❑ AVB
9. Serial nu e.�f evi `//
(r � �
12. Model nu ber o de�irA r /J
RP �
Initial
Date p�,a�da��: _
Time:
❑ PASS
❑ FAIL
Final �
Date �m�✓da�.y�:
Time:
PASS
❑ FAIL
Check Valve #1
Held at PSID
❑ Closed Tight
❑ Leaked
Held at�PSID
�losed Tight
❑ Leaked
AI R GAP
Measured vertical inches above overflow rim
15. Comments
Check Valve #2
Held at PSID
❑ Closed Tight
❑ Leaked
Held at PSID
�osed Tight
❑ Leaked
size diameter:
PVB/SVB
Air Inlet .
Opened at PSID
❑ Did Not Open
Check Valve Held PSID
Opened at PSID
� Did Not Open
Check Valve Held PSID
AVB
Yes ❑ No
15. Name and e-mail address of tester � 7. Company name of tester (r� applicable)
Initial 18. Telephone number 19. Signature and registration number of tester
Tester
20. Testing equipment serial number 21. Testing equipment calibration date (mm/dd/yy)
22. Name and e-mail address of tester 23. Company name of tester (if applicable)
Final Doron Gopstein service@gordonplumbin .com Gordon Plumbin Inc
24. Telephone number 25. Si nature a r i atian number of tester
Tester 317.845.1805 BF13-4914
26. Testing equipment serial number 27. Testing equipment calibration date (mm/dd/yy)
04162737 07/22/2019
�, By signing this backflow test report and checking this box, l hereby certify that I am familiar with the ir�formation contained in
this form and that to the best of my knowledge and belief, such information is true, complete and accurate at the time of the test
Page 2 of 2
Pressure Differential
Relief Valve
Opened at
PSID
❑ Did Not Open
Opened at�
PSID
❑ Did Not Open