Be sure to keep a copy of the form for yourself, and mail the form to: City of Davis Public Works Utilities & Operations Department Attn: Backflow 1717 Fifth Street Davis, CA 95616. 0000015936 00000 n The following numbers refer to the enclosed form. Free and easy to customize. PSID Backflow Certified Test Report Banner Operating Certificate Driveway Fence Impact Fee Irrigation Meter Downsize Permit Application Signs Swimming Pool Temporary Activity/Structure(Tent) Residential Driveway Fence Garage Sale Impact Fee Irrigation Meter Downsize Permit Application Swimming Pool . Preprinted backflow test report forms, containing the make, model, size, serial number and site location, can be obtained for any existing backflow by contacting the Water Quality Specialist. Health Services. Customize this free template without coding! A Weekly Shift Report is a form used by store owners or managers to track employee working days and hours in a week. Your account is currently limited to {formLimit} forms. The City of Fort Worth partners with Vepo, LLC for the mailing of annual testing notices and online submission of Backflow Prevention Assembly Test and Maintenance Reports. 52}pkg*:h 295 Main Street Room 350 Buffalo, NY 14203-2494. With your free Employee End of Day Report Form instantly collecting information online, youll have a cost-effective way to gather end of day reports from your employees no more messy paperwork or time-consuming daily meetings. Do you want to be a volunteer in the fire department and save a life? A job applicant reference report form is used by employers to collect references on a job applicant. Backflow Prevention Program. This is an essential part to help them develop their skills and business capabilities. LLC, Internet Backflow Prevention / Cross-Connection Control Program. Each time you run a backflow test, collect responses directly into your account. Frequently Asked Questions What is a cross-connection? Backflow prevention asssemblies must be installed and maintained to comply with City of Dallas Chapter 49, Section 19.201 and 30 TAC 290.44. REPLACED: A document handover form is used by businesses to share important documents with clients and send them on their way. Save the completed form to your device by hitting. A parking ticket form can be used by a traffic or parking officers that captured or caught a driver who illegally parked his or her vehicle. Stick to these simple instructions to get Backflow Test Report Form prepared for submitting: Get the sample you want in the library of legal templates. By using this template, the citizens can report the incident with the informations such as date and time when the incident occurred, incident location, incident details, contact information. Add the. Attn: Backow Assembly Records A backflow testing report will document the type of testing conducted and the status of the pipes. Initial Backflow Test Form. If not an annual Test, please select one of the following: New Assembly Remove Assembly Replace Assembly. They're an inexpensive and easy way for water works professionals to record findings and provide professional reports. hb```f`````ufb@ ! Whether its a complaint, incident or bug, giving one a proper way to report is pretty important. It only takes a few minutes. Design and Construction Standards for Wastewater Collection Systems. 0000008931 00000 n Select the area where you want to insert your signature and then draw it in the popup window. Lee County Utilities (LCU) is committed to helping protect your drinking water system from potential contamination through an active Cross-Connection Control (CCC) and Backflow Prevention Program. Do you want your agents to submit a productivity report on their work or assigned task? Backflow Test and Maintenance Report Form. . This form can be embedded on any webpage which makes it easily available to anyone. We provide commercial property owners an annual schedule for testing all their assemblies. PSID Building, transportation, maintenance, and sewer projects. Click, Rate Backflow Assembly Test Report Forms as 5 stars, Rate Backflow Assembly Test Report Forms as 4 stars, Rate Backflow Assembly Test Report Forms as 3 stars, Rate Backflow Assembly Test Report Forms as 2 stars, Rate Backflow Assembly Test Report Forms as 1 stars, backflow preventer inspection and field test report, Test & Maintenance (PDF) - Cape Fear Public Utility Authority. Try one of our free online report form templates today! Revision#0. People can report suspected cases of COVID-19 in their workplace or community. Important: Test reports will not be processed if they do not have the Water Bureau-provided sticker label on them. Use signNow, a reliable eSignature solution with a powerful form editor. Use professional pre-built templates to fill in and sign documents online faster. From now on comfortably get through it from home or at the office right from your mobile or desktop computer. Our First Aid Incident Report Form Template makes it easier to document incidents as they occur, so you can focus more on providing treatment when its required. 0000004893 00000 n OPENED AT: 0000016016 00000 n This Police Incident Report template is used to provide the police with notifications about an incident or matter that are considered to be non-urgent. Use our signature tool and say goodbye to the old days with efficiency, affordability and security. RUBBER KIT We recently ended free access to eliminate all the spam and Bots signing up for accounts. & Estates, Corporate - Example - Plumbing Floor Plan And Elevation View Drawing. 0 Backflow is water flowing opposite of its intended direction, either from a loss of pressure in the supply lines or an increase in pressure on the customer's side. Draw your signature or initials, place it in the corresponding field and save the changes. SubMenu3+ Annual Statistical Reports; Backflow Forms; Engineering Forms; Water Main Rehabilitation; CIP/IFR Program; 0000014998 00000 n . Nicholson Lab Inc. For Watts and Duke Test Kits 1423 Queen City Ave Cincinnati, OH 45214 513-251-8378. The whole procedure can take a few seconds. 9?b,aFnF b==I. Productivity reports are ways to determine if the agent has improved on the appointed areas or their job. Box 590, Raleigh, NC 27602- 0590 . 0000013209 00000 n DIFF. Speed up your businesss document workflow by creating the professional online forms and legally-binding electronic signatures. You can submit Temporary Food Facilities (TFFs) applications via: Email: TFF@dph.sbcounty.gov Fax: 909.387.4323 Mail: 385 N. Arrowhead Ave, 2nd Floor San Bernardino, CA 92415 After its signed its up to you on how to export your backflow test report: download it to your mobile device, upload it to the cloud or send it to another party via email. A medical report form is a document used by medical professionals for documenting a patients medical treatment. Start filling out the blanks according to the instructions: Hi my name is mark Titus I'm the instructor for Afro-American backflow prevention today I'm going to show you the test procedures for the RP assembly we will be using the USC 10th edition test procedures alright let's start our first step is to notify identify inspect and observe we're going to notify the customer that we're here to test the assembly we're going to identify the assembly we're going to check the serial number the make the model the size to make sure that we're testing the correct assembly we're going to inspect the backflow assembly make sure it has four test to approve shutoff valves as you notice on this assembly it already has pre-installed test fittings a lot of the newer assemblies come with pre-installed test fittings, so we won't have to install them during our tests because they're pre-installed alrighty let's get started first thing we need to do is flush our test we're going to turn out a test number four we're going to let that one run turn on test three we'r. Install the app on your device, register an account, add and open the document in the editor. No matter which way you choose, your forms will be legally binding. Install the signNow application on your iOS device. Job log form provides you with the job title, staff name, and date with each of the tasks that are accomplished, their start and end time, work description, materials that are used in the process, and the files related to the job. Human Resources. Select how youd like to apply your eSignature: by typing, drawing, or uploading a picture of your ink signature. BUFFER See something we could improve onthis page? Jotforms online report forms are fully customizable and completely free to use. Privacy Policy| Alternate Format Requests | Notice of Nondiscrimination, Sample Backflow Preventer Inspection and Field Test Report, File Complaint About Provider or Facility, Healthcare Enforcement and Licensing Modernization Solution, Healthcare Professional Credentialing Requirements, Veterans, Service Members and their Families, Emergency Information for Specific Groups, For Public Health & Health Care Providers, Public Health System Resources and Services, Cross-Connection Control / Backflow Prevention, Centers for Disease Control and Prevention (CDC), Local Health Jurisdictions and Tribal Directories, Northwest Center for Public Health Practice. Simply update the form fields to match your needs, make the form look better with our design tools. Collect COVID-19 test results from employees, students, customers, and more. CLEANED ONLY If so, with this form, you can also prepare a service report includes this information and many more. Read the instructions to determine which details you have to provide. Collect issue reports from company members with a free online Issue Tracking Form. Utilize a check mark to indicate the choice where needed. Ordinance to Review Chapter 15 of the Fee Scheduled (PDF) - Plan Review Fee. REPLACED: Engineering and Construction Opportunities. A missing person form is used by law enforcement agencies to collect information about missing people. PSID We Recommend using the Chrome Browser on all devices for backflowtestreport.com Links BSI Online Tracking SC Tracking Solutions Track all of this information online with Jotform! Digital Submittal Standards. All can be achieved without coding! Office: (919)-996-2747. PSID Please log in. This program is in accordance with Ordinance #95-21 and Florida Administrative Code 62-555.360. If you have any questions please contact Gary Alan Nolan . AIR INLET The form can be completed in one of two ways: The form can be printed and completed by hand, or Sync information seamlessly and collect it anywhere you need it with a free online document handover form! Select the area you want to sign and click. PSID test and maintennce report rp clean. 0000011985 00000 n Because of the ever changing nature of the building and construction industry, together with the continuing development of new technology and . Have an easier way to keep track of your counseling sessions by using this school counseling case notes template today! There are three variants; a typed, drawn or uploaded signature. A COVID-19 symptoms self-report form is a form used by medical offices to collect information from patients about their symptoms or complaints. . Just customize the form questions to match your needs, then embed the form on your website or share it with a link. There will be a $10 fee to submit tests through the SwiftComply portal. Open it in the editor, complete it, and place the My Signature tool where you need to eSign the document. Find the extension in the Web Store and push, Click on the link to the document you want to design and select. 0000001725 00000 n CV ASSEMBLY Test and Maintenance Reports should be entered online in the WEIRS . Cross Connection Program and Backflow Prevention. Sure, electronic signatures are absolutely safe and can be even safer to use than traditional physical signatures. If you have any questions, please contact KC Water Backflow Division at 816-513-4795 or email at backflow@kcmo.org. Approved Ordinance Changes (PDF) - Approved 10-15-2018 (PDF) - Irrigation Definition. Austin, TX 78744. Notification # Manufacturer; Notification # Search. View responses on any device. Testing must be conducted by a certified tester upon installation and every 12 . Preventing Backflow. USLegal received the following as compared to 9 other form sites. Contact Information. By making use of signNow's complete platform, you're able to complete any necessary edits to Get And Sign BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT CUSTOMER: ASSET #: SERVICE ADDRESS: ACCOUNT #: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RP DC MANUFACTURE: RELIEF VALVE PUB MODEL: CHECK VALVE #1 Line Pressure: SERIAL NO Form, create your customized electronic signature in a few fast steps, and streamline your workflow without the need of leaving your browser. Check Valve 1. Create an account, log in, and upload your Backflow Assembly Test Report Forms. I certify that the information provided in this Backflow Incident Report is complete and accurate to the best of my knowledge. Forget about scanning and printing out forms. Our service provides you with a wide selection of templates available for filling out on the internet. Improve the workflow of your hospital or clinic by using this COVID-19 Lab Report Form wherein it can be filled out and submit it in real-time. Backflow Prevention Device: Test Form. Here is a school counseling notes template that a counselor can use to keep track of the counseling sessions. Avoid having to deal with paper forms and exchange by collecting responses directly into your account with Jotform. This fee is only applicable for passed tests. If you cant find an answer to your question, please dont hesitate to reach out to us. Fire department run report form that allows you to report call type, the situation found, the officer in charge and units involved. New installations The T&M form must be printed and signed by a licensed tester who performed the work and a copy provided to BSI . gQXKW^-)mZ8}]k >%DdMXCzn 9iLDpo/N 7H2`$`Ko;Ajy6Np'A}x7S`k 4D`k"r#pA8$l/ PK ! Technology, Power of services, For Small 9/27/2016 university of florida treeo center test and maintenance report customer: street address: mailing address: location of assembly: type of assembly: rp dc pvb svb size: manufacturer: model: serial no: Backflow Information A+ A- Loading. PVB. startxref We have recently fixed the date issue with the Pasadena Form. . %PDF-1.6 % A workplace harassment complaint form is used to document workplace harassment complaints. After all, you don't really need all the details in many circumstances. Log in to your signNow account and open the template you need to sign. Testers certified by the State of Michigan shall test and install backflow prevention devices. Fire Service Backflow Guidelines. Reduced Pressure Principle Backflow Preventer (RP) ASSE Standard #1013 Field Test Report . A Departmental Report Form template useful for preparing daily reports regarding the department, internal issues and payroll through areas to fill/select/upload necessary information and documents with the manager contact information. Access the most extensive library of templates available. Enjoy smart fillable fields and interactivity. This is a report form for the fire modifications. Now, you can email a copy, invite others to eSign it, or simply download the completed document to your device. 0000048365 00000 n PSID 10/22/90 rev. Submitting Backflow Test Report Form does not need to be perplexing anymore. FChT-T38[KfKn-I-ANM^@nMlF_WSM;'OMf\?Duiu"zsi?YEy} Bavco Backflow Apparatus & Valve Co. For Watts and Duke Test Kits 20435 South Suzanna Rd Long Beach, CA 90810 800-458-3492. 0000005731 00000 n Whether you are running a company, restaurant or a cafe, feel free to customize this cash up sheet template. PSID Put the relevant date and place your e-signature once you fill out all of the fields. The construction site will have several pipes that carry water, waste, or both. 430$5I#Eo Connect to a strong connection to the internet and start executing forms with a fully legitimate signature in minutes. Backflow Prevention Assembly Test Report Form (PDF) All testable backflow devices are to be tested upon installation, and tested thereafter at a frequency to be determined by the DPW. To change optional fields, delete cell content and type your information in the field. Important Notice. Your companys logo, or adjust the design and layout of the form, use the Jotform Form Builder. REPLACED: Date: Account Name/Business Name: Account Address: TEST. Use this Agent Productivity Report Form make it easier for them to submit their productivity report on a daily or weekly basis. We've developed a sample test report to complement the rule. Get a dedicated support team with Jotform Enterprise. Forms, Real Estate A cross-connection is an actual or potential link connecting a source of pollution or contamination with a potable water supply. Receive submissions for COVID-19 test reports from your staff for your company or organization online. Click on the fillable fields and include the required info. Name (print): Title: Signature: CCS Cert. If youre the plumber, the contractor wont need to contact every time you need to collect information. Jotform is a fully customized, easy-to-use Form Builder that includes changing, adding, or removing fields through the drag and drop function, and changing the colors, fonts, and background without any coding required. VALVE: Take advantage of signNow mobile application for iOS or Android if you need to fill out and electronically sign the Backflow Assembly Test Report Forms on the go. !->_8ke*II3I;'jf With this volunteer fire department incident report template, you can find a volunteer firefighter. Ideal for employers meeting Santa Clara County requirements. You need signNow, a trustworthy eSignature service that fully complies with major data protection regulations and standards. To enroll, visit the SwiftComply portal at this address:www.bftester.com/dallastx, Request an Admin-style account where you can submit tests on behalf of testers in your company, Submit your Testing Certification and Test Kit Information (Please note these are required to sign up). The plumber will need to test to ensure that the pipes are properly installed and not leaking. 0000048122 00000 n Backflow Preventer Permit Application. Water services will not be disrupted. Testing varies by device type and typically takes 10 to 30 minutes. ]pZxA"&q9y2KY7~'QI8wF3@-p1ton|67i>il2snD>"#fSM3 CHECK VALVE Backflow Assembly & Test Report Form Makes Managing Backflow Test Reports as Easy as 1, 2, 3 Forms currently available: All forms - $150 yearly - unlimited for up to 5 testers Submit Form to Agency You're DONE! With a Silver or Gold plan, this HIPAA-compliant report form will keep sensitive medical information safe. A daily field report is a pre-formatted document that store information about a day's work, typically for a work crew. 0000010949 00000 n The form can be printed and completed by hand, or 2. %%EOF Optional fields appear cream shaded in the report and table. Convert to official PDFs automatically. Testers can customise test reports with their business name and logo for their customers Submit your backflow test report Want to become a smart tester? My Account, Forms in For fee sheets, click here. Water Customers with a testable backflow assembly (s) will receive an initial testing notice two months prior to the test due date. For questions or comments, please contact Regina Cahill at 937-390-5600 ext 251 or rcahill@ccchd.com . This fire alarm system report form template is to monitor, inspect, test and evaluate all the fire alarm system devices you have by gathering company details with system information, inspection details, etc. Failed tests are not charged. Use this Allegation Form to get to know about the issue or complaints about your company and get better at customer relationships easily. Response: A: Device Size 1 1 1 2 3 4 6 Testing Unit Use professional pre-built templates to fill in and sign documents online faster. Easy to customize and fill out on any device. PSID Get a backflow testing forms 0 template with signNow and complete it in a few simple clicks. Are you searching around the web for complaint form template html codes in order to create an online for that is simple, effective and easy to fill out? I would like to be added to the list of Certified Backflow Testers. Theft, Personal An asset disposal form is a form used to document the disposal process of assets. Password: Repeat Password: Firm Name: Firm Address: Firm City: Firm State: Firm Zip: Firm Phone: However, it should be noted that this is just a short character profile form that enables you to capture just the most relevant information about the characters. %%EOF With signNow, it is possible to design as many papers in a day as you need at a reasonable price. signNow's web-based DDD is specifically made to simplify the organization of workflow and improve the entire process of competent document management. No coding! USLegal fulfills industry-leading security and compliance standards. Visit Minnesota Department of Labor and industry for backflow prevention certification information. BACKFLOW PREVENTION ASSEMBLY. The City of Portland ensures meaningful access to City programs, services, and activities to comply with Civil Rights Title VI and ADA Title II laws and reasonably provides: translation, interpretation, modifications, accommodations, alternative formats, auxiliary aids and services. 0000041487 00000 n To remove optional fields, highlight the cell and press the delete button. We appreciate all of the Backflow Testers that have used our Software for many years. High-hazard backflow prevention assemblies must be tested annually by a licensed backflow tester. The purpose of form TCEQ-20700 Backflow Prevention Assembly Test and Maintenance Report (T&M Form) is to document the results of testing a backflow prevention assembly. B320 Portland, Oregon 972041926 Let employees submit daily reports online through our free Employee End of Day Report Form, which you can send via email or embed in your website for easier access you can even password protect your form to ensure its only filled out by your employees. CLEANED ONLY Get your online template and fill it in using progressive features. Send the electronic form to the intended recipient. 0000007038 00000 n Document what happens during your shift and endorse it to the next staff by using this Community Shift Report. 10 31 A metro security report form is a form used by an individual or organization to report security threats, misconduct, or other issues to the authorities. Happy New Year hb```f``qc`e`c`@ (u~Kslf -R,'=4E$0P0pHhT``d{E=C;~H%0`1d%-9lq20@| 8 Your testing notice will have a CCN (Customer Contact Number . Broward County 3XEOLF :RUNV 'HSDUWPHQW :DWHU :DVWHZDWHU 6HUYLFHV FISCAL OPERATIONS DIVISION 2555 West Copans Road, Pompano Beach FL 33069 BACKFLOW PREVENTION ASSEMBLY FIELD TEST REPORT USLegal has been awarded the TopTenREVIEWS Gold Award 9 years in a row as the most comprehensive and helpful online legal forms services on the market today. Get access to thousands of forms. Owner of Property _____ Address _____ 10 0 obj <> endobj Search for the document you need to design on your device and upload it. Administrative Office. This test form can be used to streamline the test and maintenance process. Form DOH-1013, Report on Test and Maintenance of Backflow Prevention Device. 0000041229 00000 n Follow the simple instructions below: Are you looking for a fast and efficient tool to fill in Backflow Test Report Form at an affordable price? Engineers Report For Approval Of Backflow Prevention Devices. Submit test report for RBA within 2 weeks of completion of test. This is a two part form. RUBBER KIT No-Flow Validation Test - Concerns NEWWA Backflow Test Report Form (MS Word Format) NEWWA Backflow Test Report Form (Writable PDF Format) Upcoming Courses & Brochures Click here to view all upcoming courses online. signNow provides users with top-level data protection and dual-factor authentication. CCC Program Mgr. signNow makes signing easier and more convenient since it provides users with numerous additional features like Invite to Sign, Merge Documents, Add Fields, etc. Great for IT departments. Traffic Report, Forms, Instructions & Permits. The Police Incident Report Form allows citizens to report a non-urgent incident or matter providing the information of date, time, location and any further details of the issue. The form required for reporting is included as a PDF in the link below. There is a separate hidden section which gets emailed to the EMS Chief. Opportunities posted to governmentjobs.com, Submitting backflow assembly test reports, City of Portland general information hotline, Backflow prevention and cross-connection control, state-certified contractor to test your assembly, Backflow assembly installation requirements, Legal and installation requirements for backflow protection. Backflow Prevention Assembly Test Report 701 South Miami Street West Milton, Ohio 45383-1339 Phone: 937.698.1500 www.westmiltonohio.gov Fax: 937.698.3900 As in effect on . SHUT OFF VALVE You can get documents for every purpose in the signNow forms library. Just customize the Medical Report Form to match your practice add your logo and colors, and easily add more form fields. The Cross Connection Program is responsible for ensuring potable water provided by the City remains safe throughout the water distribution system and is protected from "backflow events." (an undesirable reversal of potentially contaminated water from a customer to the City's system.). Planning, Wills Use this step-by-step guideline to complete the Get And Sign BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT CUSTOMER: ASSET #: SERVICE ADDRESS: ACCOUNT #: LOCATION OF ASSEMBLY: TYPE OF ASSEMBLY: RP DC MANUFACTURE: RELIEF VALVE PUB MODEL: CHECK VALVE #1 Line Pressure: SERIAL NO Form quickly and with idEval precision. A daily sales report is a record of transactions for a business on a daily basis. Use this Negative COVID-19 Test Reporting Form template and make your receiving process simple and manageable. Owner of Property _____ Address _____ Handbook, DUI 1/15/2010 rev. REPORT ON TEST AND MAINTENANCE OF BACKFLOW PREVENTION DEVICE PART A - To Be Completed by Certified Tester # Indicate the test year and whether initial or annual test. Backflow Prevention Assembly Test Report Return Legible and Satisfactory Reports to: WATER UTILITY AUTHORITY - COMPLIANCE DIVISION CROSS CONNECTION CONTROL OFFICE - SOUTHSIDE WATER RECLAMATION PLANT P.O. The only thing worse than dealing with an incident? The new software will increase on-time backflow tests, improve compliance and reduce administrative delays. To access the SwiftComply portal click the link below. Here is a list of the most common customer questions. 0000012232 00000 n Test reports are no longer accepted through in-person drop off, email, fax or postal mail. # Complete block and lot (if available) for New York City Metropolitan area tests. ---------------------------------------------------------------------------------------------------. Experience a faster way to fill out and sign forms on the web. 0000014015 00000 n To see the current list of approved backflow prevention devices, stop by the Water Division office, or contact the State Board's Division of Drinking Water directly at 916-449-5577 to request a copy.