Backflow Preventer Test and Inspection Form

This form must be submitted by the Property Owner, or Agent of an Industrial, Commercial, Institutional, or Multi-Residential building. The test and this test report form must be completed by a qualified person in accordance with By-Law 6213-19. In addition, the Town requires a BUILDING PERMIT for all new installations and replacements.

This Test Report is for:

A New Installation

A Replacement

An Annual Test

Section 1: Facility Information

Business/Facility Name

Street Number

Suite/Unit Number

City/ Town

Postal Code

Type of Isolation:

Premise

Zone

Source

Is this BFP Device on the Water Service Line?

Yes

No

Is there an Unprotected Branch Connection, Hose Connection, or a Split between the Water Meter and BFP Device?

Yes

No

Is this BFP Device on a Fire System?

Yes

No

Is this BFP Device on an Irrigation System?

Yes

No

Is BFP Device located in a chamber?

Yes

No

Is the premise isolation backflow device installed after the water meter and its by-pass? (Both the meter and meter by-pass must be protected by a backflow prevention device.)

Yes

No

If the by-pass is installed around the meter, is the by-pass valve closed and sealed?

Yes

No

Section 2

Information

Owner Information

Agent Information

First Name

Last Name

Phone

Email Address

Street Address/Suite/ Unit/:

City/ Town

Postal Code

Town of Aurora Water Account Number (located on water bill).

Water Meter Serial No.

Section 3: Tester Information

Certified Tester’s Name

CCC Certification Number:

OCOT Membership Number

Business Name

Email Address

Telephone Number

Street Number and Name, Suite/Unit Number

City/ Town

Test Kit Manufacturer:

Test Kit Serial Number:

Test Kit Model Number:

Calibration Expiry Date (yyyy-mm-dd)

Calibration Certificate Attached

Yes

No

Tester’s Certificate Attached

Yes

No