COUNTY OF SACRAMENTO ASSEMBLY INFORMATION

ENVIRONMENTAL MANAGEMENT DEPARTMENT

ENVIRONMENTAL COMPLIANCE DIVISON TYPE: SIZE: MFG:
10590 ARMSTRONG AVENUE, SUITE A MODEL:
MATHER CA 95655-4153 SERIAL NO.:
(916) 875-8400 i FAX (916) 854-9274 EXISTING ⇛ REFERENCE NO.:
REPLACEMENT ⇛ OLD ASSEMBLY SERIAL NO.: NEW
BACKFLOW ASSEMBLY TEST REPORT ⇛ PLUMBING PERMIT NO.:
TYPE OF SERVICE:DOMESTICIRRIGATION
WATER PURVEYOR:

IF APPLICABLE, WATER METER NO.: FIRE

BUSINESS NAME: SITE PHONE:

SITE ADDRESS: CITY: ZIP:
FACILITY

ASSEMBLY LOCATION:
(Please use dimensions and references – Lot Lines, Property Lines, Curb, and/or other permanent features/landmarks)
INTERNAL :
(Please provide location description such as name of room and/or room / unit / suite number)
HOME OR PERSONAL INFORMATION IS NOT GIVEN ON PUBLIC RECORD SEARCHES. ARE THE ADDRESS AND THE PHONE NUMBER
MANAGEMENT

BELOW FOR YOUR HOME OR BUSINESS? HOME: BUSINESS: MAILING ADDRESS CORRECTION REQUESTED
OWNER /

OWNER / CONTACT NAME (ATTN): PHONE:

MANAGEMENT NAME (C/O): CELL PHONE:
MAILING ADDRESS: FAX NUMBER:
CITY, STATE, & ZIP: OTHER:

TEST RESULTS INFORMATION

DOUBLE CHECK VALVE ASSEMBLY
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
CHECK VALVE CHECK VALVE DIFFERENTIAL
AIR INLET VALVE CHECK VALVE
NO. 1 NO. 2 RELIEF VALVE
OPENED AT: . OPENED AT: .
HELD AT: .
HELD AT: . PSID PSID HELD AT: .
INITIAL PSID
OPENED UNDER OPENED UNDER
PSID PSID
TEST CLOSED TIGHT (RP)
LEAKED 2.0 PSID OR 1.0 PSID OR LEAKED
LEAKED
DID NOT OPEN DID NOT OPEN
1) CLEANED 1) CLEANED 1) CLEANED 1) CLEANED 1) CLEANED
REPLACED: REPLACED: 2) EXERCISED REPLACED: REPLACED:
R 2) DISC 2) DISC REPLACED: 2) DISC 2) DISC
E 3) SPRING 3) SPRING 3) DISC(S) 3) DIAPHRAGM 3) MODULE
P 4) GUIDE 4) GUIDE 4) SPRING 4) FLOAT 4) OTHER
A 5) SEAT 5) SEAT 5) DIAPHRAGM(S) 5) OTHER
I 6) MODULE 6) MODULE 6) SEAT(S)
R 7) OTHER 7) OTHER 7) O-RING(S)
8) MODULE
9) OTHER
TEST HELD AT: .
HELD AT: . OPENED AT: . OPENED AT: . HELD AT: .
AFTER PSID
PSID PSID PSID PSID
REPAIR CLOSED TIGHT (RP)

INITIAL TEST TEST AFTER REPAIR COMMENTS:

START TIME: START TIME:
DATE: DATE:

ASSEMBLY: PASSED FAILED TAG NO.:

If FAILED, please mail the test report to the County and notify the appropriate water purveyor within 24 hours!
PLEASE MAIL ORIGINAL TO THE COUNTY OFFICE SAC. COUNTY TESTER
FREEZE BAG? FREEZE CAGE? NUMBER: PLEASE PRINT

THOMAS GUIDE MAP, PAGE – GRID: YOUR NAME:

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ORIGINAL: ENV. MGMT. DEPT. YELLOW COPY: CUSTOMER PINK COPY: TESTER