Get Goochland County Backflow Assembly Form - 9-4-12 Revised 4-26-13.docx

Filling out the Goochland County Backflow Assembly Form online can streamline the process of compliance with backflow prevention testing requirements. This guide provides clear and detailed instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click the 'Get Form' button to obtain the form and open it in your preferred document editor.
2. Begin with Part 1 - Owner Information. Enter the owner's first and last name, mailing address, city, state (Virginia), and zip code. If the service address differs from the mailing address, include that information as well. Provide a phone number and fax number if available. Include the permit number, if applicable, and the contact name and title if they differ from the owner.
3. Proceed to Part 2 - Assembly Information. Select the type of backflow assembly by circling or checking the appropriate option (RP, RPD, DC, DDC, PVB, SVB). Fill in the manufacturer details, size, model number, and serial number. Specify whether this is an existing assembly, a new installation, or a replacement. Lastly, provide the specific location of the assembly.
4. In Part 3 - Test Data, input the supply pressure for Check Valve No. 1. For Check Valve No. 2, document closed tight readings and any leaks. Include shut-off valve performance results and air inlet open pressure. Note whether the check valve held tight or did not open, as well as relief valve function and comments regarding repairs or parts replaced.
5. In Part 4 - Test Certification, complete the information regarding the tester including their printed name, signature, address, company name, city, state, and zip code. Ensure that you include the certification number of the tester and details about the test kit used, including manufacturer and model number.
6. After reviewing all sections, confirm that the test result is marked as either 'Pass' or 'Fail' before finalizing the document. Make a copy for your records.
7. Submit a copy of the completed form to the Goochland County Cross Connection Control Coordinator via the address or fax number provided at the top of the form no later than 30 days after completing the test.
8. You can save changes to the form, download it for additional use, print a hard copy, or share it electronically, following the options available in your document editor.

Complete the Goochland County Backflow Assembly Form online today to ensure compliance and streamline your submission process.