1 March 2006, Version 1

Plumbing and Drainage Act 2002 (s. 38 SPDR)

REPORT ON INSPECTION AND TESTING OF

BACKFLOW
Plumbing PREVENTION
and Drainage Act 2002 DEVICES,
REGISTERED AIR GAPS AND REGISTERED
BREAK TANKS
9
1. Application and type of test File Reference or BA: First test (New device) Standard Test Date of test
Retest Audit test

2. Owner/occupier and tester’s details Owner/Occupier Name Authorised Tester’s Name

Address Licence Number

Contact Person Address

Phone No/Mobile No. Phone No/Mobile No.

Site Address

3. Backflow prevention device and Location of Device

test results
.

Make and type Size Model No Serial No

Containment Protection Zone Protection Individual protection

Reduced Pressure Zone Device Pressure Type Vacuum-Breaker

Double Check Devices (column 1 & 2)

Check Valve No 1 Check Valve No 2 Differential Air Inlet Check Valve
pressure
Initial test Double check Closed tight Opened at Opened at
before closed tight
maintenance RP………..….KPA …………KPA ………..KPA …………….KPA ……………KPA
Leaked Leaked Not opened Not opened
Describe _________________________________________________________________________________
maintenance & __________________________________________________________________________________________
parts &
materials used __________________________________________________________________________________________

Test after Double check – Closed tight Opened at Opened at

maintenance Closed tight

RP…………. KPA …………..KPA ….……..KPA ………………KPA ………….KPA

Test Kit Serial No. Date Test Kit Last Verified Plumbers’ Name

Remarks

Plumbers’ Signature Date

Pass Fail
OFFICE USE ONLY
DATE RECEIVING REFERENCE
RECEIVED OFFICER’S NAME/S NUMBER/S
4. Air gap & break tanks details Location

Inlet Pipe diameter, Air gap spacing, Air gap bridged Yes Describe how air gap was
bridged or bypassed:
d1:------------------------mm h:---------------------mm or bypassed: No

Test date Tester Result:

Pass
Fail