---

Customer & Device Information

Physical Address (required)

Name of Facility (required)

Contact Person (required)

Contact Number (required)

Meter Number

Meter Class (required)

Domestic

Fire

Irrigation

Is the Device a New Assembly (required)

Yes

No

Replacing Serial Number

Date of Test

Make of Device

Model Number

Size

SN

Location of Device

---

Initial Test Measurements

Initial Test Date

Initial Test Time

Initial Test

Pass

Fail

---

Initial Test - DC

Check Valve #1 - Held PSID

Check Valve #1

Closed Tight

Leaked

Check Valve #2 - Held PSID

Check Valve #2

Closed Tight

Leaked

---

Initial Test - RP

Pressure Differential Relief Valve - Opened PSID

Pressure Differential Relief Valve

Did Not Open

---

Initial Test - PVB/SVB

Air Inlet Opened PSID

Air Inlet

Did Not Open

Air Inlet - Check Valve Held PSID

---

Test After Repair Measurements

Test After Repair Date

Test After Repair Time

Test After Repair

Pass

Fail

---

Test After Repair - DC

Check Valve #1 - Held PSID

Check Valve #1

Closed Tight

Leaked

Check Valve #2 - Held PSID

Check Valve #2

Closed Tight

Leaked

---

Test After Repair - RP

Pressure Differential Relief Valve - Opened PSID

Pressure Differential Relief Valve

Did Not Open

---

Test After Repair - PVB/SVB

Air Inlet Opened PSID

Air Inlet

Did Not Open

Air Inlet - Check Valve Held PSID

---

Air Gap

Measured Vertical Inches Above Overflow Rim

Supply Size Diameter

AVB - Opened Fully

Yes

No

Repairs & Materials Used / Comments

---

Tester Information

Test Kit Make

Model

SN

Calibration

Test Performed By

Cert. No.

Exp. Date

Business Name

Business Address

Postal Code

Business Phone

Test Method

ABPA

ASSE

Number of Hoses Used

This Assembly Test

Passed

Failed

Upload Additional Report Documents

Certify

I Certify That I Have Tested The Above Assembly And That It Meets The Performance Required By The Widefield Water & Sanitation District Regulations And I Am Certified To Comply With These Regulations.

Tester Name (required)

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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Test Report Must Be Submitted NO LATER THAN 10 DAYS Following Testing.

Failed Test Must Be Reported And Submitted Within 24 Hrs