Skip to content

Customer Service
Administration & Transparency
Water Quality & Supply
Projects & Infrastructure

Customer Service
Administration & Transparency
Water Quality & Supply
Projects & Infrastructure

Backflow Prevention Assembly Test Report

— Click Here for a Printable Form —

CUSTOMER INFORMATION

Customer Name(Required)

Address(Required)

Street Address City

Meter Number(Required)

ASSEMBLY INFORMATION

Assembly Location(Required)

Make(Required)

Model(Required)

Serial Number

Size

Test Date(Required)

Month

Day

Year

Test Report Due Date(Required)

Month

Day

Year

Installation Date(Required)

Month

Day

Year

Type of Service Performed(Required)

New Install

Existing Install

Replacement

Service Type(Required)

Domestic Water Service

Irrigation Service

Fire Service

Other

Valve Type Tested(Required)

RPPA

DCVA

PVB

Serial Number of Replaced Assembly:

Describe "Other"

INITIAL RPPA TEST RESULTS

Line Pressure at Time of Test(Required)

PSI Pressure Across No. 1 Check Valve(Required)

Relief Valve Opened at PSI:(Required)

No. 1 Check(Required)

Closed Tight

Leaked

No. 2 Check(Required)

Closed Tight

Leaked

No. 1 PST at 'Closed Tight'(Required)

No. 2 PSI at 'Closed Tight'(Required)

Passed Test?(Required)

Yes

No

Proper Installation?(Required)

Yes

No

Water Service Restored?(Required)

Yes

No

Remarks (if any)

INITIAL PVB TEST RESULTS

Air Inlet(Required)

Opened at…

Failed to Open

Check Valve(Required)

Closed Tight

Leaked

Air Inlet Opened at PSI:(Required)

Check Valve Closed Tight at PSI:(Required)

Passed Test?(Required)

Yes

No

Proper Installation?(Required)

Yes

No

Water Service Restored?(Required)

Yes

No

Remarks

INITIAL DCVA TEST RESULTS

#1 Check(Required)

Closed Tight

Leaked

#2 Check(Required)

Closed Tight

Leaked

#1 PSI at 'Closed Tight'(Required)

#2 PSI at 'Closed Tight'(Required)

Passed Test?(Required)

Yes

No

Proper Installation?(Required)

Yes

No

Water Service Restored?(Required)

Yes

No

Remarks (if any)

TESTER INFORMATION

Tester Company(Required)

Tested By

First Last

Certification Number

Tester Phone

Test Kit Make

Test Kit Model

Test Kit Serial Number

Calculation Date

Month

Day

Year

Δ

Contact Us
📍 41972 Garstin Drive, Big Bear Lake, CA 92315
📬 Mail to: P.O. Box 1929, Big Bear Lake, CA 92315-1929
⏰ Operating Hours: Mon – Fri, 8 a.m. – 4:30 p.m. (Except Holidays)
☎️ 909-866-5050
✉️ CustomerService@bigbearlakedwpca.gov