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Backflow Preventer & Cross-Connection Inspection
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An annual field test and cross-connection survey of reduced-pressure and double-check backflow assemblies protecting the potable water supply, documenting differential pressures, check-valve tightness, and relief-valve operation.
USC FCCCHR ManualAWWA M14ASSE 5000
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Assembly and Site Identification
- Property address and assembly location *
- Assembly type *
- Manufacturer, model, and size of the assembly *
- Serial number
- Degree of hazard protected against *
Installation Conditions
- Assembly is installed at the correct orientation and height above grade *
- Assembly is protected from freezing and physical damage *
- Relief-port drain and air gap are unobstructed and not submerged *
- Test cocks and shutoff valves are present and operable *
- Photo of the installed assembly
Check Valve and Relief Valve Test
- Differential pressure across the first check valve (psid) *
- Second check valve holds tight against back-pressure *
- Relief valve opens at 2.0 psid or greater *
- No continuous discharge from the relief port under normal supply pressure *
- Shutoff valves hold tight during the test *
Cross-Connection Survey
- No unprotected connections to auxiliary water sources, boilers, or irrigation observed *
- Hose bibbs are fitted with atmospheric vacuum breakers where required *
- Chemical, fire-suppression, or process piping is separated from potable lines by an approved assembly *
- Notes on cross-connection hazards found
Result and Certification
- Overall assembly test result *
- Corrective action taken or required
- Certified tester name and certification number *
- Date of test *
- Tester signature *
Backflow Preventer & Cross-Connection Inspection 체크리스트 전체 다운로드
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