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City of Grand Island, NE

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Backflow Device Testing Form

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Please correct the fields below:

Please correct the field(s) marked in red below:

Initial Test

Annual Test

Replacement Test

*

Job Address:*

Owner Address:

Occupant Name/Phone:

Owner Name/Phone:

Water Meter #:

Installation Date:

Manufacturer: *

Model #: *

Serial #: *

Device Size: *

Test Date: *

Location: *

Device Type (Check One):

*

Device Type (Check One):

Atmospheric Vacuum Breaker (AVB)

Dual Check Valve (DCV)

Double Check Valve (DBL)

Pressure Vacuum Breaker (PVB)

Reduced Pressure Zone (RPZ)

33.33%