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City of Bonney Lake - Public Works

crossconnect@cobl.us

19306 Bonney Lake Blvd. Bonney Lake, WA 98391

253-447-3227

Backflow Prevention Assembly Test Report

RETURN TO:
Water Quality Section
19306 Bonney Lake Blvd.
P.O. Box 7380
Bonney Lake, WA 98391
Phone: 253-447-3227
Fax: 253-447-4330
Email: crossconnect@cobl.us

Pick One

Service Address

Customer Name

Check if

Hazard Type

Type:

Proper Install

Initial Test

Initial Test

DCVA/RPBA Check Valve No. 1

DCVA/RPBA Check Valve No. 2

PVBA/SVBA Air Inlet

New Parts and Repairs

PVBA/SVBA: Check Valve

Test After Repairs

Test After Repairs

Pass or Fail

Confined Space:

Tester's Signature

Choose how to sign

Tester's Printed Name