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Security Water District

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Security Water District
Backflow Prevention Device Test and Maintenance Report
Type
Installation
only 30 days to repair or replace Failed Device

Reduced Pressure Devices

Pressure Vacuum Breaker

Double Check Devices
Relief Valve
Air inlet
Check Valve

Initial Test

1st Check
2nd Check
Opened at psi
Opened at psi

Repairs & Materials used

Initial Test

1st Check
2nd Check
Opened at psi
Opened at psi
Results may be scanned and emailed to [email protected] or placed in the white drop box near the front door at 231 Security Blvd. Colorado Springs Co. 80911 or mailed to the same address. For questions call: (719) 392-3475

The undersigned certify this report to be true and accurate and the cross control device tested on this form was accomplished in accordance with the applicable regulations of the Security Water District and the Colorado Department of Public Health and Environment, CDPHE

Revised 3/2020

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