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4. CUSTOMER INFORMATION
6. Address of Device*
7. Owner / Manager*
9. Phone Number*
10. Mailing Address*
12. Contact Person First Name*
13. Contact Person Last Name*
17. INSPECTION INFORMATION
19. Type of Inspection*
    -- Select One --ResidentialCommercialMulti-Family
20. Type of Service*
    -- Select One --Fire LineIrrigationPoolResidential Fire SprinklerService LineOther
22. Pass / Fail*
    -- Select One --PassFail
23. Type of Test*
    -- Select One --AnnualNew DeviceRe-inspection (after failed inspection)
25. Existing Device?*
    -- Select One --ExistingNewReplacement
29. DEVICE INFORMATION
31. Make & Model*
32. Size*
33. Type of Device*
    -- Select One --Reduced PressureDouble Gate / Double CheckPressure Vacuum BreakerSpill Proof Vacuum BreakerSingle Check Valve
35. Serial Number*
36. Location of Device*
38. INSPECTION & TEST GAUGE MEASUREMENT
40. Check Valve #1
42. Static PSID*
43. Check Valve*
    -- Select One --Closed TightLeaked
45. Check Valve #2
47. Static PSID*
48. Check Valve*
    -- Select One --Closed TightLeaked
50. Pressure Differential Value
52. Open at PSID*
53. Did Not Open

    1. Check Here if It Did Not Open
55. PVB/SPVA Air Inlet
57. Open at PSID*
58. Did Not Open

    1. Check Here if It Did Not Open
60. Check Valve Held (PSID)*
61. Leaked

    1. Check Here if Leaked
65. Backflow Prevention Device Worker Information
67. Tested By*
68. Company Name*
69. Company Phone #*
71. Test Gauge Number*
72. Calibration Date*
    Calibration Date
73. Test Gauge Certificate

    Attach 1 file. Only needed if not already provided to the Town.

75. Backflow Certificate #*
76. Backflow Certificate

    Attach 1 file. Only needed if you have not already provided your current certificate to the Town.

78. ADDITIONAL DOCUMENT UPLOAD

    Attach any additional information needed as 1 file.

80. 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.

    By submitting this backflow test report, I hereby certify that I am currently certified as a Backflow Protection Assembly Tester, certified within Virginia's DPOR, and familiar with the information contained in this form and that to best of my knowledge and believe, such information is true, complete, and accurate at the time of this test.

    1. I agree.
82. Electronic Signature
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field